health nutrition and education

School health and nutrition

Good health and nutrition are foundations for learning and a crucial investment for more sustainable, inclusive and peaceful futures – they can improve education outcomes, empower learners to thrive and promote inclusion and equity in education and health.

What is the state of school health and nutrition around the world?

The good news is that:

• 9 in 10 countries globally invest in school health and nutrition programmes.
• More than 100 countries have school vaccination programmes.
• One in two primary school children receives school meals
• Almost every country includes education for health and well-being in its curriculum.

And yet many children, in particular girls, are missing out especially in the poorest countries.

• 73 million of the most marginalized children are not reached by school feeding, undermining their ability to benefit from education.
• Over 246 million learners experience violence in and around school every year.
• 1 in 3 schools do not have basic drinking water and adequate sanitation.

Developed by UNESCO and five UN partners (UNICEF, WFP, FAO, GPE, and WHO), in collaboration with the World Bank, the Research Consortium for School Health and Nutrition and the UN-Nutrition Secretariat,  Ready to learn and thrive  takes stock of countries’ policies and programmes around health and nutrition, and underscores school health and nutrition as an effective and affordable way to ensure learners learn and thrive throughout their education pathway and beyond. 

What does health and nutrition mean for learners and schools?

School health and nutrition is about investing both in learners’ education  and  their health, with benefits extending to homes and communities. Ensuring the health and well-being of learners is one of the most transformative ways to improve education outcomes, promote inclusion and equity and to rebuild the education system, especially following the COVID-19 pandemic.

The report shows that healthy, well-nourished and happy children and adolescents learn better and are more likely to lead healthy and fulfilling lives. For example, learners are 50% less likely to skip school when the learning environment is free from violence; absenteeism is reduced in low-income countries when promoting handwashing in particular for girls during menstruation when water, sanitation and hygiene is improved, and enrolment rates increase when school meals are provided to learners.

What are some of the key challenges?

Despite significant progress on school health and nutrition, more work must be done to ensure that the programmes in place are comprehensive, meet the needs of  all  learners and can be sustained. Many children are still missing out, especially in the poorest countries and most marginalized communities.

While the multisectoral nature of school health and nutrition is a strength, it can also lead to diffused action and scattered interventions. More attention needs to be paid to the quality of progammes, the synergies with existing efforts and the monitoring and evaluating of actions’ delivery and impact.

As the world is facing a global food crisis and struggling with the devastating effects of the COVID-19 pandemic, school health and nutrition must be integral to the daily mission of education systems across the globe.

What can we do about it?

To transform education and the lives of children and adolescents, this publication urges governments and development partners to put learners’ health and well-being at the core of the education agenda and to improve the quality and reach of school health and nutrition programmes.

We need comprehensive policies and programmes that address  all  learners’ needs holistically, are relevant and responsive to contexts and evolving needs, coordinated across sectors and sustained by increased policy and financial commitments.

There are many ways in which schools can promote physical and mental health and well-being. This starts by including health and well-being in curriculum, providing nutritious school meals and ensuring access to health services. It also means ensuring that school environments are free from violence and conducive to good health, nutrition, development and learning. Greater efforts to engage learners and communities and to ensure school staff and teachers have the necessary knowledge, tools and support are also needed.

School health and nutrition actions are a cost-effective investment. They can help reach marginalized learners and advance inclusion and equity, while benefitting multiple sectors including education, health, social protection and agriculture.

How does UNESCO work to advance school health and nutrition?

At UNESCO, school health and nutrition are core parts of its education mandate. We know that children and youth learn better when they are happy, healthy and thriving in school. This means that their learning environment must feel safe, offer healthy meals and promote physical and mental health.

Guided by its  Strategy on education for health and well-being , UNESCO offers technical advice and resources, and fosters resilient and health-promoting education systems. The  Global Standards for Health-Promoting Schools  by UNESCO and WHO, for example, supports countries to adopt and institutionalize a holistic approach that promotes the physical and mental health and well-being of all learners.

The COVID-19 pandemic has demonstrated the interlinkages between education and health and the urgent need to work together across sectors. This is especially the case around the mental health of learners post-COVID. In Chile for example, UNESCO provided technical advice to the  Seamos Comunidad  programme which addresses the effects of the pandemic through a focus on improved relations and infrastructures, and better mental health and learning in school.

Through its work with governments, partners and civil society, UNESCO seeks to create and support education and school systems that foster a safe and healthy learning environment, enabling learners to thrive and get the most benefits out of their education. A series of guidance and tools were produced by UNESCO to help countries respond to  school violence and bullying ,  school-related gender-based violence , and other forms of violence in and around school.

School health and nutrition for every learner

Partner commitments

• Download  the global report  and the  highlights  from the report
• Social media pack
• Press release:  Educational achievement is hampered by lack of investment in health and nutrition
• GPE blog:  School health and nutrition are needed to unlock the potential of every child
• Read about a good practice in Malawi:  How Wezzie is inspiring her students to make healthy choices in school and life in Malawi

Transforming education: Putting learners’ health and well-being first

More resources

• UNESCO strategy on education for health and well-being
• Stepping up effective school health and nutrition: a partnership for healthy learners and brighter futures
• The journey towards comprehensive sexuality education: global status report
• UNESCO Health and education resource centre
• UNESCO’s work on education for health and well-being
• Ready to learn and thrive: Release of the report on school health and nutrition around the world , video of the launch webinar, 3 February 2023

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Nutrition is a critical part of health and development. Better nutrition is related to improved infant, child and maternal health, stronger immune systems, safer pregnancy and childbirth, lower risk of non-communicable diseases (such as diabetes and cardiovascular disease), and longevity.

Healthy children learn better. People with adequate nutrition are more productive and can create opportunities to gradually break the cycles of poverty and hunger.

Malnutrition, in every form, presents significant threats to human health. Today the world faces a double burden of malnutrition that includes both undernutrition and overweight, especially in low- and middle-income countries. There are multiple forms of malnutrition, including undernutrition (wasting or stunting), inadequate vitamins or minerals, overweight, obesity, and resulting diet-related noncommunicable diseases.

The developmental, economic, social, and medical impacts of the global burden of malnutrition are serious and lasting for individuals and their families, for communities and for countries.

Most recent estimates show that globally, 149.2 million children under the age of 5 years of age are stunted (too short for their age) and 45.4 million are wasted (underweight for their height).  The number of children with stunting is declining in all regions except Africa. Over three-quarters of all children suffering from severe wasting live in Asia.

Around 45% of deaths among children under 5 years of age are linked to undernutrition. These mostly occur in low- and middle-income countries.

Anaemia is a serious global public health problem that particularly affects young children and pregnant women. WHO estimates that 40% of children less than 5 years of age and 37% of pregnant women worldwide are anaemic. Thirty percent of women of reproductive age have anaemia.

Globally, 1.9 billion adults are overweight or obese and 38.9 million children under 5 years of age are overweight. Rates of childhood overweight and obesity are rising, particularly in high-income and upper-middle-income countries.

Although breastfeeding protects against undernutrition and overweight, only 44% of infants under 6 months of age are exclusively breastfed.

High sodium consumption (>5 g salt/day) contributes to high blood pressure and increases the risk of heart disease and stroke. Most people consume too much salt – on average 9–12 grams per day, or around twice the recommended maximum level of intake.

According to the 2016–2025 nutrition strategy, WHO uses its convening power to help set, align and advocate for priorities and policies that move nutrition forward globally; develops evidence-informed guidance based on robust scientific and ethical frameworks; supports the adoption of guidance and implementation of effective nutrition actions; and monitors and evaluates policy and programme implementation and nutrition outcomes.

This work is framed by the Comprehensive implementation plan on maternal, infant, and young child nutrition, adopted by Member States through a World Health Assembly resolution in 2012. Actions to end malnutrition are also vital for achieving the diet-related targets of the Global action plan for the prevention and control of noncommunicable diseases 2013–2020, the Global strategy for women’s, children’s, and adolescent’s health 2016–2030, the report of the Commission on Ending Childhood Obesity (2016), and the 2030 Agenda for sustainable development.

In May 2018, the Health Assembly approved the 13th General Programme of Work (GPW13), which guides the work of WHO in 2019–2023. Reduction of salt/sodium intake and elimination of industrially produced trans-fats from the food supply are identified in GPW13 as part of WHO’s priority actions to achieve the aims of ensuring healthy lives and promote well-being for all at all ages.

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Health Educator’s Nutrition Toolkit: Setting the Table for Healthy Eating

En Español (Spanish)

The Health Educator’s Nutrition Toolkit is designed to help health educators, dietitians, physicians, other health care and nutrition professionals, social workers, youth counselors, and program directors teach consumers about the Nutrition Facts label and how to use the information it provides to make healthier food choices. The Toolkit offers a wide range of resources, including realistic tips on how to shop for and prepare food as well as order food when eating out to build a healthy diet.

The Toolkit includes:

• An introductory guide with information on how to use the toolkit (for health educators) (PDF - 1MB)
• Tip Sheet #1: Tips for Making Healthy Choices While Food Shopping (PDF - 15545KB)
• Tip Sheet #2: Tips for Bringing Nutrition into Your Home (PDF - 545KB)
• Tip Sheet #3: Tips for Making Healthy Choices When Eating Out (PDF - 409KB)
• Tip Card: Quick Tips for Reading the Nutrition Facts label (PDF - 273KB)
• A PowerPoint presentation, including notes, split into two sections – “Understanding the Nutrition Facts label” and “Bringing Nutrition Into Your Daily Life” (PPT - 43.4MB)
• Evaluation tools: a pre-test (DOC - 75KB) / post-test (DOC - 76KB) (10-15 questions) to accompany the PowerPoint presentation
• An infographic with tips on using the Nutrition Facts label and MyPlate when planning, shopping, cooking, and eating (PDF - 823KB)

Sample social media posts with nutrition education messages and graphics

Share the social media messages and graphics below to encourage your audience to make healthier choices at home and while dining out.

Sample Posts

DYK Americans eat and drink about one-third of their calories away from home? Use these tips from @FDAFood to make healthier food and beverage choices while dining out. www.fda.gov/media/131159/download

Healthy cooking and eating starts at the grocery store. Make healthy food purchases by reading the Nutrition Facts label. Here’s what to look for: www.fda.gov/media/131160/download .

Even small shifts to healthier food options can add up to healthy lifelong changes. Learn how: www.fda.gov/media/131191/download .

Commit to healthier choices at home and while dining out. Here are some tips from @FDAFood to help! www.fda.gov/media/131159/download .

Is grocery shopping on your to-do list? Bring @FDAFood’s Tip Card with you to help you make healthy choices www.fda.gov/media/131162/download .

Sample Facebook Posts

Looking up nutrition information BEFORE you dine out can help you make healthier choices away from home. Check restaurant websites, phone apps, and menus. Once you have the nutrition information, choose items lower in calories, saturated fat, trans fat, sodium, and added sugars. www.fda.gov/media/131159/download .

Did you know Americans eat and drink about one-third of their calories away from home? Use these 3 tips to help you make healthier choices while dining out: www.fda.gov/media/131159/download .

Commit to healthier choices at home and while dining out. These easy tips from FDA’s Nutrition Toolkit can get you started: www.fda.gov/media/131159/download and www.fda.gov/media/131160/download .

Take time to choose healthy options, whether you are food shopping, cooking or eating out. Even small shifts to healthier options can add up to healthy lifelong changes. www.fda.gov/media/131160/download .

Shop smart! Read the Nutrition Facts label when food shopping to make healthier choices for you and your family. www.fda.gov/media/131160/download .

Looking for more? Share one of our social media messages at @FDAFood on X , U.S. Food and Drug Administration on Facebook and Pinterest .

FDA has additional Nutrition Education Resources and Materials for a variety of audiences, which can be used along with the Toolkit for planning and conducting nutrition education programs and individual instruction.

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Explore resources, tools, and printable materials on nutrition for healthy adults. See tips on healthy eating, vegetarian diets, and foods for athletes.

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Understanding Food Insecurity and Its Effects on Gestational Diabetes Risk Among American Indian and Alaska Native Females Can Lead to Better Outcomes

Sarah A. Stotz, PhD, RDN, CDCES, Department of Food Science and Human Nutrition, Colorado State University, presents the results of a new study assessing the risk of gestational diabetes in Native adolescent and young adult females due to food insecurity. Reducing gestational diabetes through a culturally informed approach to care and health education is essential for fostering healthy eating habits.

Read the Article

Evaluating Diet Quality in Community Café Meals for Individuals Facing Food Insecurity

Alexandra L. MacMillan Uribe, PhD, RDN, Texas A&M Institute for Advancing Health Through Agriculture, highlights a new study that found meals from a community café had significantly higher diet quality than meals eaten elsewhere, as measured by the Healthy Eating Index. Investigations like these are crucial for developing effective strategies to promote healthier eating habits in vulnerable populations through community-based food programs like community cafés.

The Society for Nutrition Education and Behavior (SNEB) Issues Its Position on How to Address Emergency Food and Nutrition Needs in Disaster Preparedness

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Inclusive Care: Strategies to Support Infant Feeding for Parents with Disabilities Through WIC

Noelene K. Jeffers, PhD, CNM, IBCLC, Johns Hopkins School of Nursing, highlights the need for inclusive care to support and educate parents with intellectual and developmental disabilities with infant feeding through WIC. Dr. Jeffers discusses a new study that found that WIC can address disparities by offering inclusive and accessible support and counseling. Formally educating and training WIC staff to offer care that is respectful and responsive to the needs of disabled parents is crucial.

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The Journal of Nutrition Education and Behavior ( JNEB ), the official peer-reviewed journal of the Society for Nutrition Education and Behavior   Opens in new window     , since 1969, serves as a global resource to advance nutrition education and behavior related research, practice, and policy. JNEB publishes original research, as well as papers focused on emerging issues, policies and practices broadly related to nutrition education and behavior. These topics include, but are not limited to, nutrition education interventions; theoretical interpretation of behavior; epidemiology of nutrition and health; food systems; food assistance programs; nutrition and behavior assessment; and public health nutrition.

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The Nutrition Source

Healthy Living Guide 2023/2024

Mindful eating

Plate and the Planet

Elevate your plate

Spotlight on artificial sweeteners

The Healthy Eating Plate

Create healthy, balanced meals using this visual guide as a blueprint.

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Safety, Health, and Nutrition in Early Childhood Education

(7 reviews)

Jennifer Paris, College of the Canyons

Copyright Year: 2018

Publisher: College of the Canyons

Language: English

Formats Available

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Learn more about reviews.

Reviewed by Jeanne Tardiff, Department Chair & Professor, Tidewater Community College on 6/20/24

This book is VERY comprehensive; it exceeded my expectations for covering my course learning objectives. The content is easy to follow and rigor is appropriate for my 100-level course. read more

Comprehensiveness rating: 5 see less

This book is VERY comprehensive; it exceeded my expectations for covering my course learning objectives. The content is easy to follow and rigor is appropriate for my 100-level course.

Content Accuracy rating: 5

Content is accurate and unbiased. The statistics provided were as up to date as possible and can be easily changed in the Google Document.

Relevance/Longevity rating: 5

The content is up to date and easily editable.

Clarity rating: 5

The text is easy to read and provides adequate context for any possible jargon or technical terminology.

Consistency rating: 5

The text is consistent and organized well. Students can easily locate information throughout each chapter.

Modularity rating: 5

The units are split in a logical manner and each chapter scaffolds from the prior chapter. The chapters break down into smaller sections that could be easily assigned as stand-alone requirements.

Organization/Structure/Flow rating: 5

The topics in this book are presented in a logical flow and they are easy to read. The relationship to the prior chapters are evident.

Interface rating: 4

The text does not show and significant interface issues. However, it would be helpful to include hyperlinks to each chapter in the Table of Contents.

Grammatical Errors rating: 5

The text contains no grammatical errors.

Cultural Relevance rating: 5

The book successfully promoted diversity, equity, and inclusion by both providing separate chapters/sections on culture/ability content and integrating it into the whole book.

This book exceeds my expectations in content; covering all of my course learning outcomes and more. It is very comprehensive; yet easy to read. It is of the perfect rigor for my 100-level health, safety, and nutrition class.

Although there is no index, I appreciate the "Resources for Further Exploration" websites at the end of each chapter. These could be used in many ways; specifically to support student work on accompanying assignments. On the OpenStax website, there appear to be no ancillary materials, but at the beginning of the book, a link for a Google Conversation can be found. This offers some great resources and allows instructors to collaborate. I especially value the video observation library. There was also a lot of information found in the many appendices in the back of the book.

This book integrates much diversity in ability, culture, and gender. For instance, children's mental health is covered in chapter 11. This is a growing topic that needs to be studied by early childhood educators. In addition, the book covered topics such as trauma and adverse childhood experiences. The book even includes general guidance on religious food choices for many cultures!

The beginning of each chapter identifies licensing standards that align with the chapter and that is helpful. It could easily be re-created with the adopters' state licensing regulations. It would be helpful to also align the NAEYC Standards for Professional Preparation in each chapter.

The sources used were all very credible and research-based. Not only so, but the content was developmentally appropriate in many ways. For example, in discussing biting, it explored other reasons for biting (communicating) than just something to admonish the child for. The book included much NAEYC content, which aligns perfectly with our NAEYC Accreditation.

Reviewed by Deb Merrigan, Instructor, Normandale Community College on 3/1/24

The text covers key topics related to child safety, health, and nutrition. Missing are index and glossary sections. In addition, key oral health components related to child safety, health and nutrition are not addressed. read more

Comprehensiveness rating: 2 see less

The text covers key topics related to child safety, health, and nutrition. Missing are index and glossary sections. In addition, key oral health components related to child safety, health and nutrition are not addressed.

The content appears to accurate and unbiased. This book provides a sufficient degree of depth and scope in the safety, health, and nutrition related to early childhood education.

The content appears to be up-to-date. One of the strengths of this book is that it is arranged in a way that to allow for necessary updates to be easily applied.

The text is written in lucid, accessible prose. It consistently provides adequate context for each topic discussed. In addition, definitions of terminology are provided within the chapters to provide adequate context and meaning.

Similar content is grouped together and the heading and body styles are consistent throughout the book. The text is divided into smaller reading sections that the reader will find easy to navigate.

The text maximized readability and minimizes distractions. A nice feature throughout the chapters are callout boxes that help draw attention to information and prompt the reader to think more about the content they have just read.

The structure of the text is consistent, logical, and efficient. The layout and design, broken down by sections on safety, health, and nutrition create an easy path for readers to follow. In addition, the Appendix section which houses forms, checklists, and other relevant information is organized in a logical flow by topics.

Interface rating: 5

The text navigation facilitates ease of movement throughout the book. Images, tables, and callout boxes are appropriate, meaningful and clear to the reader.

Grammatical Errors rating: 4

Overall, editing and proofreading errors are minimal.

Cultural Relevance rating: 4

The text aims to be sensitive to gender inclusiveness. Unless language was pulled from source content, the term child or adult is referred to with the pronoun they or them. In addition, efforts were made to use the terms caregivers or guardians to be inclusive of all families. Also, person first language is utilized.

Addressing oral health related to safety, health and nutrition is a key component missing in this book. For safety, needed is information on oral health signs of child maltreatment. For health and nutrition, a deeper dive into caries risk and prevention is needed. There is a brief mention in Ch. 1 on risks for dental caries (cavities) under the subheading Understanding Childhood Health Concerns. Consider listing information on risk factors for tooth decay and how untreated cavities can cause pain and infections that may lead to problems with eating, speaking, playing, and learning. In addition, what educators, caregivers, and staff can educate families and/or caregivers on cavity prevention related to oral home care and diet.

Reviewed by Dawn Hendricks, Instructor, Clackamas Community College on 2/17/22

The textbook is quite comprehensive and provides thorough information on all aspects of health, safety and nutrition in early childhood settings. Unfortunately, there is not an index, which would make navigating the book more efficient. ... read more

The textbook is quite comprehensive and provides thorough information on all aspects of health, safety and nutrition in early childhood settings. Unfortunately, there is not an index, which would make navigating the book more efficient. However, the table of of contents at the front is detailed, providing an outline of the four different sections and fifteen chapters of the book. There is a robust appendix at the end with helpful resources such as health and safety checklists.

The content is accurate and un-biased. Since the author of the book teaches at a community college in California, there are some California-specific references and information which not be relevant to programs in other states. However, that information could easily be omitted or passed over.

The information on health, safety and nutrition in the book is current and up to date. The statistics that are used and the research that is referenced is current within the past few years. Given the way the book is formatted into smaller chapters and sections, it would be relatively easy to update the book as needed to maintain its relevance.

The language level used in the book makes it accessible for community college students as well as potentially high school students. When educational jargon is used, brief explanations of the terms or concepts are provided.

Each of the fifteen chapters are consistent in terms of organization, structure and framework. This makes the contents very reader-friendly and inviting.

The main topics of the book, saftey, health and nutrition, each have their own section. These could easily be re-organized, given the sequence of a particular course. Within each of those three primary sections, there are chapters, which lend themselves to easily being re-organized or even omitted if need be.

The book is well-organized and presents the contents in a clear, logical sequence.

There were no discernible issues with the interface.

Grammatical Errors rating: 3

There were some grammatical errors and spelling typos in the book, particularly in the appendix. Appendix N particularly had several errors.

With the images, contents and examples, the book is inclusive of other cultures.

I do plan to use this book beginning in Fall 2022 in one of my courses. The course currently is "Nutrition, Music and Movement". However, given the comprehensive nature of this book, and the already existing need to re-design the course to align with other community colleges, I will be updating the course to "Safety, Health and Nutrition in Early Childhood".

We are also planning to translate this OER into Spanish.

Reviewed by Dawn Behan, Professor of Education; Director of Graduate Education Program, Mount Mercy University on 12/27/21

This textbook is quite thorough in the content areas of safety, health, and nutrition for early childhood students; however, it fails to include the necessity of teachers and child care providers being trained in CPR for children in early... read more

Comprehensiveness rating: 4 see less

This textbook is quite thorough in the content areas of safety, health, and nutrition for early childhood students; however, it fails to include the necessity of teachers and child care providers being trained in CPR for children in early childhood: infants, toddlers, and pre-schoolers, as well as K-3rd grade students. It begins with a comprehensive Table of Contents which describes the text’s four main sections: Section I, Introduction; Section II, Safety; Section III, Health; and Section IV, Nutrition. These sections are followed by a list of 16 appendices. Next, the Preface tells the reader about the following sections: Licensing of Source Content, Language Choices Throughout This Book (i.e., Terminology, Gendered Language, Family Structures and Forms, Person First Language), and Special Features Throughout the Book (i.e., Licensing Regulations, Pin It!, Pause to Reflect, Engaging Families, In the Classroom, and Resources for Further Exploration, and more). References are given on each page via footnotes. There is no Glossary or Index included in this text. Both would have been helpful in navigating this textbook. Although the author alludes to the difficulty in providing consistent terminology in the text, a glossary of terms would enhance an understanding of the vocabulary used in the text. Also, an index would be helpful in locating specific topics and information in the text, such as Trauma Informed Care, because only chapter headings are listed in the Table of Contents.

Content Accuracy rating: 4

The content appears to be accurate and current; however, most content comes from resources that are web-based. Thus, the absence of dates on these resources must be taken into consideration, and resources should be checked for currency of content. Nonetheless, most content that is from dated sources seems to be fairly recent (i.e., within the past 3-15 years). The content included in the text appears to be unbiased; the content used in this text is from sources noted in footnotes on each page of the text.

Because the content appears to be fairly up-to-date, the content should not be obsolete within a short period of time. The text is written and structured in a way that updates to the content should be relatively easy to implement.

The text is written in understandable language, and text boxes with examples, important information, and further resources are included and highlighted to add clarity to the text's vocabulary.

The text uses consistent language and consistent text features which allow the reader to identify information that can enhance their understanding of the content throughout the text. For instance, one text feature, Pin It! uses examples and focuses on specific information that relates to the topic in the chapter. A couple of other text features, Pause to Reflect and In the Classroom, provide suggestions on how to apply the content. The author does note the inconsistency of early childhood terminology, as the text was compiled from “hundreds of sources” (Paris, 2020, p. 6).

The text is divided into four sections, and each section is further divided into chapters (there are a total of 15). This text could easily be divided into four modules or by chapter for more specific, focused discussions. This text could be used for online, virtual, or Face-to-Face course delivery models.

Bolded sections, chapters, and subheadings; bulleted lists; text boxes; photos; figures; and tables are included to create an organized, structured flow throughout the text. These text features enhance the organization of the text content and complement the content information found in the regular (not bold) print.

This text is available on the internet and can be downloaded for reader preference. However, the reader needs to be aware there may be a charge on some websites if they choose to download more than the content presented for previewing the text. There did not appear to be any display features that may distract the reader.

There are a number of mechanical and grammatical errors throughout the text. The text requires major proofreading and editing to make it appear professional. There is a note on p. 3 of the text under the heading, “Have Feedback or Resources to Share?” about what to do if the reader sees a typo. There are too many to point out in this textbook.

The text is culturally neutral. Examples of this are the following, as noted in the text on pp. 6-7: the pronouns they or them was used as much as possible “to be more gender inclusive,” the word family was used in place of the word parents to be more inclusive of different family structures, and person- first language was used in an attempt to be respectful to students who encounter different living situations (e.g., poverty) or experience different personal characteristics (such as disabilities or medical conditions).

Overall, I liked this textbook. However, I would hesitate to adopt it for an education course due to all of the mechanical and grammatical errors in it.

Reviewed by Susan Driscoll, Adjunct Faculty, Massasoit Community College on 6/30/21

The text is well organized and comprehensive. read more

The text is well organized and comprehensive.

The information is accurate and current.

The text is relevant and will help students apply the information in their classrooms. If it is used in a state other than California, the state licensing regulations will need to be reviewed.

The text is easy to comprehend. It is well written.

The terminology is consistent and up-to-date.

The chapters are easy to break down into sections.

Organization/Structure/Flow rating: 4

The text is organized to make it easy to comprehend. Main ideas are highlighted in boxes and coded to help students organize the information. An index would be helpful.

I didn't have any issues.

The text is free from grammatical errors. There are forms in the appendix that do have some significant errors.

The text is culturally sensitive.

I have not used this text but will in the future!

Reviewed by jennifer kearns fox, faculty, Roxbury Community College on 6/30/21

The book is VERY comprehensive. It includes information on the following; Children’s Well-Being and Early Childhood Education, Safety (physical, social, emotional, environmental) and injury and illness prevention, basic first aide and safety... read more

The book is VERY comprehensive. It includes information on the following; Children’s Well-Being and Early Childhood Education, Safety (physical, social, emotional, environmental) and injury and illness prevention, basic first aide and safety information, abuse & neglect (I link to MA state agencies), overall health and wellness, caring for children with special needs, and nutrition. I recommend this book for a health safety nutrition class OR chapters for special needs courses or foundational courses in ECE. I find each chapter useful and relevant and in my courses use most chapters and include links to MA state agencies and NAEYC & Head start supports.

As stated above, the book is comprehensive and does include most pertinent information around supporting health, safety, and nutrition in ECE. Though I find it accurate I stress the importance of pairing this with local, state and federal resources. For example, I write this in June 2021. Much has changed in the landscape of the world and with this topic in regard to COVID, protocols, safe care, immunizations, etc.

Please see above. Comprehensive, relevant, accurate.

This text is very easy to use, read, and understand. I recommend it for PD, parents, college courses, and as a resource to child care settings.

This text is well organized and consistent.

Though this is well organized, I do use the chapters out of order. I do find that the organization and information is easy to pair with other chapters. For example, you can read chapter 5 after chapter 9.

See above. The organization is clear, logical, and easy to understand or reorganize for your work/purposes.

I used a phone and computer and could access the entire text. I do recommend using a computer. I used 3 browsers (chrome, explorer, and firefox) and had no issues accessing or moving between chapters.

I did not edit this book. There are no obvious errors. I was NOT looking for errors in a published OER text.

This book is culturally sensitive.

Reviewed by Sandra Scialabba, Instructor, Midlands Technical College on 4/25/21

This book is the most comprehensive one that I have found. It covers every aspect of safety, health, and nutrition as it relates to children from birth to 8 years old. It covers topics that are overlooked, or not as emphasized, in other textbooks,... read more

This book is the most comprehensive one that I have found. It covers every aspect of safety, health, and nutrition as it relates to children from birth to 8 years old. It covers topics that are overlooked, or not as emphasized, in other textbooks, such as car seat safety, using technology and media safely, what to look for on labels of art supplies to identify whether or not they have passed a toxicology review, taking into consideration developmental milestones and how they impact children's behaviors, reasons why toddlers bite, diagram explaining why the safest sleeping position for an infant is on his back, and feeding children who have special needs.

Facts are accurate, and current. The resources used are current and up to date.

The book has covered the objectives needed for an early childhood program. It will be easy to add up dates as needed. At this particular time, the only thing I can think of to add is information about COVID-19. The only reason I would choose not to use this book is that it is specific to the licensing regulations in California, which is overseen by the Community Care Licensing Division of the California Department of Social Services. Since I am an instructor in South Carolina, I would need to revise each section in every chapter that correlates to licensing regulations to correlate to the specific licensing regulations provided by The Division of Early Care and Education through the Department of Social Services in South Carolina.

This book is easy to read and understand. Students will not have any trouble comprehending the content. It is easy to understand how to put the safety, health and nutritional information into practice in a variety of child care settings.

The terminology used is not only consistent, it is also current and relevant for today's society and student.

This book is easy to breakdown into sections for class reading and homework assignments. It will be easy to include in an online format, such as D2L, because it is already divided into short chapters.

I would recommend that the Table of Contents have a Section V: Appendix A-P The Appendix is currently included in Section IV: Nutrition Throughout the book, some of the references to the Appendix aren't worded consistently with the title of the document. For example: Page 102 refers to "checklists" in Appendix E, however, there is only one checklist. Page 232 refers the reader to Appendix J for more information on illnesses, however, it should refer the reader to Appendix M. Page 243 refers the reader to Appendix K, however, it should refer the reader to Appendix J. There are other examples like these that need to be revised.

No interface issues noticed.

No grammatical errors noticed.

The text is culturally sensitive. The pictures and examples used, as well as the relevant content provided throughout the book, show diversity with respect to races, ethnicities, and backgrounds. The book is sensitive to using "people first" language and recognizes that what constitutes a family is going to be different for each child. Some examples include: Chapter 7 highlights the culture of sleep, referring to the ways and places that people sleep. Some people sleep inside, outside, in beds, on hammocks, on mats, on the floor, alone, with children, only at night, etc. This chapter also highlights that Developmental Screening Tools need to be culturally sensitive. Chapter 11 highlights that culture influences every aspect of human development, including mental health. Chapter 15 highlights that menu planning needs to take into consideration cultural and religious beliefs.

The special features included throughout the book are especially helpful. These features are easily identifiable through the use of color-coded "callout boxes" containing symbols. They include: Licensing Regulations Pin It! Pause to Reflect Important Information Quotes Engaging Families In the Classroom Resources for Further Exploration

I highly recommend this book if you are an instructor in California. If you are an instructor in any other state, you will need to make revisions that reflect your particular state licensing regulations.

Table of Contents

Preface Section I: Introduction

• Chapter 1: Children’s Well-Being and Early Childhood Education

Section II: Safety

• Chapter 2: Preventing Injury & Protecting Children’s Safety
• Chapter 3: Creating Safe Indoor Environments
• Chapter 4: Creating Safe Outdoor Environments
• Chapter 5: Caring for Minor Injuries and Preparing for and Managing Emergencies
• Chapter 6: Child Maltreatment

Section III: Health

• Chapter 7: Promoting Good Health & Wellness
• Chapter 8: Prevention of Illness
• Chapter 9: Supportive Health Care
• Chapter 10: Children with Special Health Care Needs
• Chapter 11: Children’s Mental Health

Section IV: Nutrition

• Chapter 12: Basic Nutrition for Children
• Chapter 13: Protecting Good Nutrition and Physical Wellness 
• Chapter 14: Providing Good Nutrition
• Chapter 15: Menu Planning and Food Safety

Ancillary Material

About the book.

Early childhood is a critical time in development. Many outcomes, both positive and negative, have their beginnings in these years. It is vital that children’s health and safety be protected. High-quality early care and education programs can play a valuable role in improving outcomes for children.

About the Contributors

Jennifer Paris  is a full-time faculty member of the Early Childhood Education Department. She previously taught Child Development courses as an adjunct for Rio Hondo College in Whittier for 11 years, MiraCosta College in Oceanside for 6 years, and Cerritos College in Norwalk for 3 years. Her special interests include OER (open educational resources) and online teaching. She has cared for and taught children of all ages and had experiences throughout her schooling in campus Child Development lab schools.

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Nutrition and Healthy Eating

Goal: improve health by promoting healthy eating and making nutritious foods available..

Many people in the United States don’t eat a healthy diet. Healthy People 2030 focuses on helping people get the recommended amounts of healthy foods — like fruits, vegetables, and whole grains — to reduce their risk for chronic diseases and improve their health. 1 The Nutrition and Healthy Eating objectives also aim to help people get recommended amounts of key nutrients, like calcium and potassium.

People who eat too many unhealthy foods — like foods high in saturated fat and added sugars — are at increased risk for obesity, heart disease, type 2 diabetes, and other health problems. Strategies and interventions to help people choose healthy foods can help reduce their risk of chronic diseases and improve their overall health.

Some people don’t have the information they need to choose healthy foods. Other people don’t have access to healthy foods or can’t afford to buy enough food. Public health interventions that focus on helping everyone get healthy foods are key to reducing food insecurity and hunger and improving health.

Objective Status

Learn more about objective types

Related Objectives

The following is a sample of objectives related to this topic. Some objectives may include population data.

Nutrition and Healthy Eating — General

Adolescents.

• Heart Disease and Stroke

Overweight and Obesity

Other topics you may be interested in.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. (2015). 2015-2020 Dietary Guidelines for Americans. Retrieved from https://health.gov/our-work/food-nutrition/2015-2020-dietary-guidelines/guidelines/

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

You will be subject to the destination website's privacy policy when you follow the link.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

National Institute of Environmental Health Sciences

Your environment. your health., nutrition, health, and your environment, what is niehs doing, further reading, introduction.

What we eat is considered an environmental factor that influences health, in positive and negative ways. Healthy diets with an optimal balance of nutrients help people accomplish daily physical activities and mental processes. Within your diet, a deficiency or excess of certain nutrients can affect health.

The term diet refers to foods and beverages consumed over time in all settings, such as worksites, schools, restaurants, and the home. Diet also often means a specific nutritional plan or eating pattern.

Nutrition is the process of consuming, absorbing, and using nutrients from food that are necessary for growth, development, and maintenance of life.

What Are Nutrients?

Nutrients give your body energy and enable bodily functions. They are usually classified in two major groups:

• Macronutrients , in the form of protein, carbohydrate, or fat, primarily provide energy to your body. The different macronutrients serve different energy pathways and functions in the body. Energy from macronutrients in food is measured in units called calories.
• Micronutrients , known as vitamins and minerals, are required by the body in minute amounts. They protect and promote various bodily functions, including processing energy from macronutrients. Although critical to health, micronutrients do not supply energy.

What Should People Eat?

As reflected in the federal Dietary Guidelines for Americans , scientific evidence shows that healthful eating patterns can help people achieve and maintain well-being and reduce their chance of chronic disease. The guidelines also say that people can enjoy foods that meet their personal needs and cultural preferences while eating healthfully.

By translating science into succinct, food-based guidance, the guidelines are intended to help the U.S. population at large choose a better diet. Specific nutritional recommendations for individuals suffering from diet-related conditions are not provided.

The Dietary Guidelines for Americans are jointly developed and issued by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services. Updated every five years, they are the cornerstone for many federal nutrition programs and policies.

Why Study Nutrition and Health?

More than half of U.S. adults – 129 million people – have one or more preventable chronic diseases, such as cardiovascular disease, high blood pressure, type 2 diabetes, and some cancers, which are often related to diet and physical inactivity.

Beyond health effects, nutrition-related diseases create strains on productivity, health care spending, health disparities, and military readiness . Addressing such issues requires understanding interrelated biological and social environmental determinants, and corresponding solutions.

As a scientific field, nutrition is integral to health promotion and disease prevention. Information from many disciplines, including anthropology, biology, biochemistry, economics, epidemiology, food science and technology, genetics, physiology, psychology, and sociology, are applied in nutritional studies. Scientists consider what people eat and drink, and take as dietary supplements, during different life stages and over time. They focus on interconnections to build evidence for public policy, health system, and environmental improvement strategies.

Nutrition Research at the National Institutes of Health

The Precision Medicine Initiative is a long-term research project at NIH. This initiative aims to understand how a person's genetics, environment, and lifestyle can determine the best approaches to prevent or treat disease.

As part of the Precision Medicine Initiative, NIH has a plan to accelerate nutrition research. While dietary guidelines and related public health approaches can help improve nutritional status across a population, researchers have growing appreciation for how different factors may affect people differently.

NIH nutrition research will help answer: what should I eat to stay healthy ?

The 2020 – 2030 Strategic Plan for NIH Nutrition Research focuses on how nutrition and dietary patterns affect all health conditions and emphasizes the importance of understanding variation among people. NIEHS assists with the coordination and implementation of this nutrition research plan.

With funding and support from NIEHS, scientists are looking at whether certain nutritional components may protect people’s health when they are exposed to harmful chemicals and other environmental hazards. Scientists are also studying whether environmental factors can worsen health conditions related to nutrition or dietary patterns.

Nutrition May Reduce Harmful Health Effects From Environmental Factors

The concept of reducing risk from harmful exposures tends to mean removing or decreasing exposure to environmental contaminants. But that form of prevention can be difficult to achieve. An alternative concept is to focus on nutrients with potential to be protective or reduce the risk of harmful health effects from environmental factors.

Researchers at the NIEHS-funded University of Kentucky Superfund Research Center have an innovative, long-running program that studies if and how nutrition can reduce the risk of harmful health effects from environmental pollutants. Their research is based on the premise that nutrition should be considered a necessary variable in the study of human diseases associated with exposure to environmental contaminants.

Based on years of study, there is evidence that certain aspects of nutrition are protective and should be integral in efforts to intervene or prevent toxic health effects of some environmental factors.

For example, the researchers uncovered how a person’s diet can protect against the harmful health effects of exposure to polychlorinated biphenyls (PCBs). Now banned from production, PCBs were once commonly used in making products such as heat transfer fluids and coolant in electric transformers. They discovered that certain nutrients, vitamin E and omega 3-fatty acids , can reduce cell damage from PCB exposure and that a type of fiber found in vegetables can potentially protect against cardiovascular problems related to PCB exposure. Conversely, they also found that dietary fat that is high in linoleic acid can worsen the cardiovascular effects of PCBs.

Other Findings From NIEHS-supported Research Include the Following:

ADHD – Researchers demonstrated that low vitamin D during pregnancy was related to an increased risk of attention deficit hyperactivity disorder (ADHD), a finding that could lead to new prevention measures.

Asthma – Asthma is a common childhood disease that disproportionately affects urban minority populations. Researchers discovered that vitamin D has a protective effect among children with asthma who live in urban environments with poor indoor air quality. In other words, obese children with blood levels low in vitamin D had worse asthma than children with higher vitamin D levels.

A diet deficient in antioxidants--micronutrients that help defend cells in the body--has been suggested as one reason for the asthma epidemic. The traditional Mediterranean diet typically includes foods rich in antioxidants such as vegetables, fruits, nuts, fish, and olive oil, with a low intake of meat. This diet pattern has been shown to be protective of asthma and allergic disease in multiple studies. A study funded by NIEHS found that following this type of diet reduced the chance of asthma development among children in Lima, Peru.

Autism Spectrum Disorder – Autism spectrum disorder (ASD) is a broad range of conditions that affect communication and behavior. Environmental factors and genetics are thought to contribute to ASD, which affects 1 in 36 children in the U.S.

While more research is needed on the potential role nutrition may play in the development of ASD, studies reveal promising findings.

• Taking a prenatal vitamin during early pregnancy was associated with a lower rate of ASD in a 2021 study. This finding indicates that prenatal vitamins or supplemental folic acid could be preventative for ASD.
• The younger siblings of children with ASD have a greater chance of developing the disorder due to shared genetics and similar environment. A NIEHS-funded researcher reported, in 2019, that when mothers of these children took prenatal vitamins with folic acid in the first month of pregnancy, the recurrence of autism was reduced by about half . Folic acid is the synthetic form of folate, also known as vitamin B-9, which is found in many foods, such as dark-green leafy vegetables, beans, peas, broccoli, and oranges.

Autoimmune Diseases – Lupus, an autoimmune disease, occurs when your body's immune system attacks your own tissues and organs, affecting many different body systems. Lupus can flare up when genetically predisposed people encounter certain environmental agents, such as air pollutants, pesticides, or other chemicals. A study funded by NIEHS found that dietary micronutrients could either improve or worsen lupus symptoms . Study results suggest that dietary modification, such as more vitamin B-12, zinc, and folic acid, might be a therapeutic approach warranting further investigation in lupus patients.

Other NIEHS-funded research indicates that adequate vitamin D levels may be important for preventing immune dysfunction in older people.

Brain Health – Consuming omega-3 fatty acids, found in fish and flaxseed oil, may protect against brain shrinkage in older women who live in areas with high levels of air pollution called fine particulate matter (PM2.5).

Women living in locations with higher PM2.5 had significantly less white matter in their brains, a sign of shrinkage. But in those locations, women with high blood levels of omega-3 fatty acids had white matter that appeared healthier.

Cancer – More than 20 years ago, NIEHS researchers demonstrated a gene-diet interaction in a study that found isothiocyanates, a compound in cruciferous vegetables (e.g., broccoli, cauliflower, and cabbage), was protective against lung cancer.

In-house researchers at NIEHS found that vitamin D supplementation may be useful in breast cancer prevention . The study looked a group of women with a higher risk of developing breast cancer. The women who had high blood levels of vitamin D and regularly took vitamin D supplements had lower rates of postmenopausal breast cancer over a 5-year follow-up period.

Cardiometabolic disorders – These conditions include cardiovascular problems, diabetes, and nonalcoholic fatty liver disease. Dietary fiber may protect against metabolic and fatty liver diseases related to perfluorooctoane sulfonate (PFOS) exposure, according to a NIEHS-funded study  in mice. Study results may be useful for designing intervention strategies to reduce disease risk in PFOS-exposed populations.

A NIEHS-funded study found that triclosan , an antimicrobial found in medical soaps and household products, accelerated development of fatty liver, fibrosis, and nonalcoholic fatty liver disease  in mice that ate a high-fat diet. Understanding the molecular mechanisms by which triclosan disrupts metabolism and the gut microbiome, while also stripping away liver cells’ natural protections, may provide a basis on which to develop therapies.

Obesity is a chronic health condition that increases the chance of developing cardiometabolic disorders. High lead levels during pregnancy were linked to child obesity in a large study, partially funded by NIEHS . Children born to women who have high blood lead levels are more likely be overweight or obese, compared to children whose mothers have low levels of lead in their blood. But women who take folic acid supplements during pregnancy may reduce the chance that their children are obese.

Inflammation – Many epidemiological studies provide evidence that cardiovascular diseases are linked to environmental pollution . NIEHS-funded researchers found that a mix of B vitamins (folic acid, B-6, and B-12) may protect DNA in immune cells from harmful effects of PM2.5 air pollution. They found that this pollution caused changes in DNA related to inflammation and metabolism, which may be tied to cardiovascular or respiratory conditions. According to the researchers, dietary supplementation with B vitamins almost completely prevented the changes to DNA that may lead to adverse health effects.

Reproductive Health – There is growing acceptance that nutrition may be related to fertility, and specifically the success of infertility treatment in women. NIEHS-funded research found that women consuming a “pro-fertility” diet that included supplemental folic acid, vitamin B12, vitamin D, low-pesticide fruits and vegetables, whole grains, seafood, dairy, and soy foods have a greater chance of live birth following assisted reproductive technologies.

The same researcher found folic acid could counter the adverse effects of air pollution on reproductive success in women using assisted reproductive technology. Air pollution can harm reproduction through a variety of biological mechanisms, including oxidative stress, endocrine disruption, DNA methylation, an altered immune response, and inflammation. Given exposure to traffic-related air pollution, pregnant women who took folic acid had a greater chance of their pregnancy resulting in a live birth .

Environmental Factors Affect Nutrition

Eating Fish – Eating fish can provide many health benefits, but consumers should be cautious. Some types of fish caught in certain areas are lower in mercury, PFAS, and other contaminants than other fish. Fish consumption advisories help people understand what fish are safe to eat, for whom, and in what quantities.

Researchers supported by NIEHS, for example, developed the Eat Fish, Choose Wisely guide for North Carolina residents, which includes a color-coded map for people to identify areas where they can catch fish that are safer to eat.

Fish consumption during pregnancy is a complex scientific topic. Other NIEHS-supported researchers created a framework for untangling questions about the risks and benefits of fish consumption. It could help produce clearer guidance on fish consumption for pregnant mothers .

A 2024 study found that people who frequently eat seafood may have an increased risk of exposure to PFAS, and this source of exposure may be underestimated. Among all types of seafood sampled in the study, the highest PFAS concentrations were found in shrimp and lobster. The New Hampshire-based researchers said that because PFAS are in many aspects of the environment, it is unclear where and how these chemicals enter the marine food chain. More research is needed.

Food Environments – A systematic review published in 2020, partially funded by NIEHS, suggests that the health of some children may be affected by food environments near schools . Researchers examined the presence of fast-food outlets, convenience stores, supermarkets, and grocery stores near schools along with measures of overweight/obesity by race/ethnicity, gender, grade, and income level.

This review found that when fast food outlets were located near schools, obesity rates were generally higher among children in all grade levels. Additional research is needed to better understand this finding, especially for children at higher risk of obesity, such as those from socio‐economically disadvantaged populations.

Food Packaging – PFAS are a group of more than 15,000 perfluoroalkyl and polyfluoroalkyl substances , a class of chemicals associated with harmful health effects, including liver damage, cancer, and impaired immunity . Due to wide-spread usage, PFAS are in the blood of nearly every American , according to the Centers for Disease Control and Prevention.

• Some PFAS have grease-repellent properties and were added to food packaging. A National Science Foundation study, in 2017, found PFAS coatings on 46% of food-wrap papers and 20% of paperboard containers collected from fast-food restaurants across the U.S. In a subsequent, related NIEHS-funded study, consumption of meals from fast food, and pizza and other restaurants, was generally associated with higher serum PFAS concentrations in people . In the same study, consumption of microwave popcorn was associated with significantly higher serum levels of certain PFAS chemicals. A 2024 study by the international Food Packaging Forum identified 68 PFAS in various food contact materials, including paper, plastic, and coated metal.
• In February 2024, FDA announced that grease-proofing materials containing certain PFAS are no longer being sold for use in food packaging in the U.S.

Food Safety – Food safety studies funded by NIEHS include contaminants in common foods. In particular, arsenic, a metal-like element that can harm many human organs, presents a global food contamination problem.

Researchers measured arsenic concentrations in several rice-based products. They found high levels of arsenic in brown rice syrup , a substitute for corn syrup in many foods including toddler formula. This discovery informed the Food and Drug Administration’s Inorganic Arsenic in Rice Cereals for Infants: Action Level Draft Guidance for Industry and other federal actions and reports.

The problem of contaminants in food led researchers funded by the Superfund Research Program to develop approaches for addressing soils used to grow crops. Some are working on phytoremediation approaches that are cost-effective and ecologically friendly. Phytoremediation is a process that uses fast-growing plants in engineered systems to degrade, extract, contain, or immobilize contaminants from soil or groundwater .

One team is testing a species of a non-food crop plant called oilseed to absorb and concentrate arsenic in its stems and leaves. Once harvested, these plants could be safely destroyed through incineration. Then, the plan is for farmers to plant food crops in the soil remediated from arsenic. This project is ongoing through 2025.

Food Gardening – The need for affordable, healthy foods has increased public interest in home, school, and community gardens. While urban gardens provide numerous benefits, soil contamination may be an issue. Some NIEHS-funded researchers have taken on safe urban gardening in their community engagement projects. Examples include:

• Producing videos about safely gardening in areas where soil may have contaminants.
• Testing soil for lead and other contaminants and raising awareness of children’s health risks associated with exposure.
• Reducing exposures of urban gardeners to soil contaminants by empowering communities to implement effective, community-based exposure mitigation strategies.
• Evaluating arsenic in vegetables commonly home grown and the potential risk from consumption.
• Transforming former brownfield sites into community gardens with safe soil .

Food Security – Diet is widely recognized as a key contributor to human gut microbiome composition and function. A healthy gut microbiome can help the immune system develop, protect against pathogens, and enable proper food digestion. Researchers found the gut microbiome of adults with food insecurity , a lack of access to healthy food, differed from those who were food secure. This study is significant because it focused on a social factor rather than dietary components.

Intramural Research

The following large projects, conducted in-house at NIEHS, have research components that concern dietary patterns or nutrition.

Agricultural Heath Study – More than 89,000 farmers and their spouses in Iowa and North Carolina have been involved in this study since 1993. The collaborative research effort involves investigators from NIEHS, National Cancer Institute, Environmental Protection Agency, and National Institute for Occupational Safety and Health. This research project includes a dietary survey. A list of published papers is organized by year.

The Sister Study – From 2003 to 2009, more than 50,000 women across the U.S. and Puerto Rico, who were 35-74 years old and whose sister had breast cancer, joined this landmark research effort to find causes of breast cancer. Because of their shared environment, genes, and experiences, studying sisters provides a way to identify risk factors for breast cancer, which may lead to prevention. Participants complete health updates each year, which include dietary surveys. A list of published papers is organized by year.

Infant Feeding & Early Development Puberty Study (IFED-2) – This research study is looking at what babies eat and how they grow, including hormonal changes, into adolescence. It will improve understanding of why some kids go through puberty earlier or later than others. The age when puberty starts may be linked to a person’s future health.

NIEHS Clinical Research Unit

CaREFREE Study: Calorie Restriction, Environment, and Fitness: Reproductive Effects Evaluation – Women who develop irregular menstrual cycles may find it difficult to become pregnant. Researchers want to learn more about functional hypothalamic amenorrhea, an improperly performing hypothalamus in the brain, and how it can cause a woman’s period to stop temporarily. Dietary patterns and exercise may affect this function and change menstrual cycles. The CaREFREE study will look at how these factors may affect some women.

Stories from the Environmental Factor (NIEHS Newsletter)

• Diet and Exposures in Pregnancy: Grantee Tackles Research, Messaging (September 2023)
• Chemicals Formed in Well-done Cooked Meats May Be Risk Factors for Parkinson’s (September 2023)
• Anticancer Effects of Dietary Methionine Depend on Immune Status (September 2023)
• Folate’s Protective Effects May Now Extend to PFAS (July 2023)
• Baking Industry Food Additive Raises Red Flag, Expert Says (June 2023)
• Eating Fish While Pregnant: Benefits Outweigh Harms (June 2023)
• High-Fiber Diet May Protect Against Exposure to PFOS (April 2023)
• Precision Nutrition Improves Health at Individual Level, Expert Says (February 2023)
• Path to Food Safety Requires Multidisciplinary Approach, Experts Say (January 2023)
• Autism Researcher Focuses on Maternal Diet, Prenatal Exposures (October 2022)
• Effects of Flame Retardants, Maternal Diet on Children Focus of Talks (September 2022)
• Links Between Nutrition, Exposures, and Autism Focus of NIEHS Event (July 2022)
• North Carolina Fish Forum Turns Research Collaboration Into Action (July 2022)
• Diet holds key to slowing biological aging, researchers say  (November 2021)
• Good Nutrition Can Help Counter Effects of Contaminants, Expert Says (September 2021)

Printable Fact Sheets

Fact sheets.

Arsenic and Your Health

Autoimmune Diseases and Your Environment

Drinking Water and Your Health

Environment and Health A to Z

NTP Botanical Dietary Supplements Program

• Campaign Promotes Eating Safer Fish (2022) – The “ Stop, Check, Enjoy! ” campaign helps fishers in southeastern North Carolina understand the risks of consuming certain fish from the Cape Fear River.
• Community-engaged Research Leads to Soil Cleanup (2022) - Emory University works with residents of Atlanta’s Westside community to test their urban gardening soil for lead. This effort led to awareness of health risks and the removal of lead-contaminated soil in neighborhoods.
• Botanical Safety (2021) – Cynthia Rider, Ph.D., a toxicologist at NIEHS, describes how certain botanical dietary supplements may affect health and how consumers can make informed decisions.

Additional Resources

• Dejunking Your Diet: The Drawbacks of Ultra-Processed Foods (February 2024) – This NIH News in Health story says eating too much ultra-processed foods may lead to weight gain and increase risk for certain diseases. Tips for healthier eating are also given.
• Foodborne Diseases and Nutrition (NIEHS) – Climate change may affect foodborne illness, nutrition, and food security, which can affect many populations.
• Healthy Food Environments – From the CDC, learn about supports for people in making healthier food choices.
• National Agricultural Library, Food and Nutrition Information Center – For health professionals, this entity provides access to trustworthy food and nutrition resources from both government and non-government sources.
• NIH Office of Nutrition Research – Information about nutrition-related research funding opportunities at NIH.
• Nutrition – Public health nutrition information from the CDC.
• USDA Food and Nutrition – This federal department works to increase food security and reduce hunger by providing children and low-income people better access to a healthful diet and nutrition education.

Related Health Topics

• Gene and Environment Interaction
• Perfluoroalkyl and Polyfluoroalkyl Substances (PFAS)
• Safe Water and Your Health

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Childhood Nutrition Facts

Healthy eating in childhood and adolescence is important for proper growth and development and to prevent various health conditions. 1,2 The Dietary Guidelines for Americans, 2020–2025 recommend that people aged 2 years or older follow a healthy eating pattern that includes the following 2 :

• A variety of fruits and vegetables.
• Whole grains.
• Fat-free and low-fat dairy products.
• A variety of protein foods.

These guidelines also recommend that individuals limit calories from solid fats (major sources of saturated and trans fatty acids) and added sugars, and reduce sodium intake. 2 Unfortunately, most children and adolescents do not follow the recommendations set forth in the Dietary Guidelines for Americans . 2–4

Healthy eating can help individuals achieve and maintain a healthy body weight, consume important nutrients, and reduce the risk of developing health conditions such as 1,2

• High blood pressure.
• Heart disease.
• Type 2 diabetes.
• Osteoporosis.
• Iron deficiency.
• Dental caries (cavities).

The US Department of Agriculture provides healthy eating plans through MyPlate.gov .

• Schools are in a unique position to provide students with opportunities to learn about and practice healthy eating behaviors. 15
• Eating a healthy breakfast is associated with improved cognitive function (especially memory), reduced absenteeism, and improved mood. 16–18
• Adequate hydration may also improve cognitive function in children and adolescents, which is important for learning. 19–23  
• Between 2001 and 2010, consumption of sugar-sweetened beverages among children and adolescents decreased, but still accounts for 10% of total caloric intake. 10
• Between 2003 and 2010, total fruit intake and whole fruit intake among children and adolescents increased. However, most youth still do not meet fruit and vegetable recommendations. 11,12
• Empty calories from added sugars and solid fats contribute to 40% of daily calories for children and adolescents age 2–18 years—affecting the overall quality of their diets. Approximately half of these empty calories come from six sources: soda, fruit drinks, dairy desserts, grain desserts, pizza, and whole milk. 4   Most youth do not consume the recommended amount of total water. 13
• CDC School Nutrition Environment
• Dietary Guidelines for Americans, 2020–2025
• National Cancer Institute’s Risk Factor Monitoring and Methods: Food Sources Data on US dietary intake of the top food sources
• School Health Guidelines to Promote Healthy Eating and Physical Activity
• Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary Health and Human Services and the Secretary of Agriculture . Washington, DC: US Department of Health and Human Services; 2015.
• US Department of Health and Human Services and US Department of Agriculture. 2015–2020 Dietary Guidelines for Americans . 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/ .
• Krebs-Smith SM, Guenther PM, Subar AF, et al. Americans do not meet federal dietary recommendations. Journal of Nutrition. 2010;140:1832–1838.
• Reedy J, Krebs-Smith SM. Dietary Sources of Energy, Solid fats, and added sugars among children and adolescents in the united States. Journal of the American Dietetic Association. 2010;110:1477–1484.
• Institute of Medicine. Preventing Childhood Obesity: Health in the Balance . Washington, DC: The National Academies Press ; 2004.
• Kushi LH, Byers T, Doyle C, et al. American Cancer Society guidelines on nutrition and physical activity for cancer prevention: Reducing the risk of cancer with healthy food choices and physical activity. A Cancer Journal for Clinicians 2006;56:254–281.
• Kaiser LL, Townsend MS. Food insecurity among US children: Implications for nutrition and health. Topics in Clinical Nutrition. 2005;20:313–320.
• Alaimo K, Olson CM, Frongillo EA. Food insufficiency and American school-aged children’s cognitive, academic and psychosocial developments. Pediatrics  ,2001;108:44–53.
• Kleinman RE, Murphy JM, Little M, et al. Hunger in children in the United States: Potential behavioral and emotional correlates. Pediatrics, 1998;101:1–6.
• Mesirow MA, Welsh JA. Changing beverage consumption patterns have resulted in fewer liquid calories in the diets of US children: National health and nutrition examination survey 2001–2010. Journal of the Academy of Nutrition and Dietetics . 2015;115(4):559–66.
• Kim SA, Moore LV, Galuska D, et al. Vital Signs: Fruit and vegetable intake among children—United States, 2003–2010. MMWR . 2014; 63(No. RR-31):671–6.
• Drewnowski A, Rehm CD. Socioeconomic gradient in consumption of whole fruit and 100% fruit juice among US children and adults. Nutr J. 2015;14:3.
• Drewnowski A, Rehm CD, Constant F. Water and beverage consumption among children age 4–13 years in the United States: Analyses of 2005–2010 NHANES data. Nutr J. 2013;12(1):85.
• US Department of Agriculture. MyPlate.gov .
• Centers for Disease Control and Prevention. School health guidelines to promote healthy eating and physical activity. MMWR . 2011;60(RR05):1–76.
• Taras HL. Nutrition and student performance at school. Journal of School Health. 2005;75:199–213.
• Rampersaud GC, Pereira MA, Girard BL, et al. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. Journal of the American Dietetic Association. 2005;105:743–760.
• Hoyland A, Dye L, Lawton CL. A systematic review of the effect of breakfast on the cognitive performance of children and adolescents. Nutrition Research Reviews. 2009;22:220–243.
• Popkin BM, D’Anci KE, Rosenberg IH. Water, hydration, and health. Nutrition Reviews. 2010;68(8):439–458.
• Kempton MJ, Ettinger U, Foster R, et al. Dehydration affects brain structure and function in healthy adolescents. Human Brain Mapping. 2011;32:71–79.
• Edmonds CJ, Jeffes B. Does having a drink help you think? 6 to 7-year-old children show improvements in cognitive performance from baseline to test after having a drink of water. Appetite. 2009;53:469–472.
• Edmonds CJ, Burford D. Should children drink more water? The effects of drinking water on cognition in children. Appetite. 2009;52:776–779.
• Benton D, Burgess N. The effect of the consumption of water on the memory and attention of children. Appetite. 2009;53:143–146.

Healthy Youth

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Master of Public Health in Nutrition

Acquire skills in nutrition practice, policy, and communication along with foundational knowledge in  nutritional science, epidemiology, and public health.

The Harvard Chan School offers a Master of Public Health (MPH)-65 degree that explores the role nutrition plays in the health and well-being of the world’s populations from a variety of vantage points; recognizing the vast array of influences on diet, nutrition, and health—including environmental, socioeconomic, political, and cultural factors.

Core coursework (totaling 65 credits) emphasizes methodological strategies to develop, analyze, and evaluate interventions, programs, and policies typically used in public health nutrition and will be reinforced in unique practicum projects.

As a student in this program, you will:

• Choose from a variety of electives tailored to your personal career goals. Focused areas of interest may include: nutrition policy, health disparities, nutrition epidemiology, global health, social and behavioral sciences, and environmental sustainability. You may also develop your own focused area of interest.
• Practicum topics cover a variety of interests, such as culinary nutrition, national school and feeding programs, community nutrition, and global health. Topics may also involve opportunities within Harvard-affiliated teaching hospitals.
• Apply critical reading skills to enhance your ability to effectively communicate and translate nutrition information to the public, in the workplace, and in the media.

Watch below: Two Harvard Chan representatives answer questions about the MPH program.

Program Overview

The course schedule for the Harvard T.H. Chan School of Public Health is accessible through my.harvard Course Search . To view courses, select the “Harvard Chan School” button under browse courses, or use the search bar and filters.

Core program required courses (13.75 credits)

• ID 201 Introduction to Epidemiology and Biostatistics, Fall 1 st year (7.5)
• ID 100 Foundations for Public Health, Summer – Fall 1 1 st year (1.0)
• MPH 101-105 Core Course Sequence, varies (5.25)

MPH Practicum course and Integrative Learning Experience (7.5 credits)

• NUT 965s Practicum course, Part I, Spring 1 st year (1.25)
• Practicum, Summer after 1 st year
• NUT 965f Practicum course, part II, Fall of 2 nd year (1.25)
• NUT232 Designing and Eval. Behavioral Interventions Targeting Diet & Physical Activity – Integrative Learning Experience (ILE), Fall of 2 nd year (5.0)

Nutrition required courses (17.5 credits)

• NUT 200 Introduction to Nutrition Science, Fall 1 st year (2.5)
• NUT 201 Introduction to Public Health and Nutrition, Fall 1 st year (2.5)
• NUT 202 The Biological Basis of Human Nutrition, Spring 1 st year (5.0)
• NUT 203 Nutrition Seminar Part I, Fall 1 st year (2.5)
• NUT 206 Nutrition Seminar Part II, Spring 1 st year (2.5)
• NUT 213 Nutrition Translation and Behavior Changes, Spring 1 st year (2.5)

Area of Interest, 3 courses of shared interest (7.5 – 15 credits)

• Examples of topics and courses are available (or students can create their own). A total of 3 courses are required to meet the Area of Interest.

Frequently Asked Questions

The MPH-65 program in Nutrition is suitable for those both early in their careers or established in their careers, who wish to develop or further their expertise in nutrition. Prospective students will need to meet the following criteria:

• A bachelor’s degree from an accredited institution. Most successful applicants will have achieved a grade point average of 3.0 and above (out of a 4.0 requirement)
• At least two years of post-baccalaureate work
• Previous coursework in the biological sciences is preferred but not required

For more information on GRE and other application requirements, visit the Harvard Chan School Office of Admissions .

The MPH-65 program in Nutrition prepares those early in their careers for positions across a broad spectrum, ranging from state and local agencies to federal and international public health agencies; non-governmental organizations; non-profit and charitable organizations or donor-aid agencies; the health care industry; the food industry; as well as entrepreneurship or research coordination.

Sample Employers for MPH Nutrition Graduates May Include:

• State and Local Agencies (ie. WIC)
• Federal Public Health Agencies (USDA, FDA, CDC, NIH, etc)
• International Public Health Agencies (WHO, USAID)
• Non-Government Agencies
• Non-Profit Organizations
• Charitable Organizations
• Health Care Industry
• Academia/Research (study coordinator role)
• Food Industry
• Entrepreneurship

Sample Job Titles for MPH Nutrition Graduates May Include:

• SNAP-Ed Educator
• WIC Nutritionist or Director
• Community Health Nutritionist
• Extension Specialist
• Farm to School Coordinator
• Food Policy Director
• Nutrition Epidemiologist
• Nutrition Educator
• Nutrition Communications Specialist
• Nutrition Specialist
• Nutrition Officer
• Program Manager
• Technical Advisor
• Project Manager
• Health Promotion Disease Prevention Coordinator
• Study Coordinator
• Food Labeling Specialist
• Worksite Wellness Director
• Health Improvement Project Manager
• Program Coordinator
• Food and Nutrition Consultant
• Food and Nutrition Journalist/Author
• Study Manager
• Policy Director
• Nutrition Policy Advocate
• Food and Nutrition Analyst
• Nutrition Scientist
• Manager of Nutrition Services
• Food and Nutrition Advisor
• Public Health Nutritionist
• Director of Health and Nutrition
• Childhood Obesity Prevention Fellow

Source: Bureau of Labor Statistics, Tufts University, University of Minnesota, George Washington University

The program is typically full-time, and runs for 1.5 years (3 semesters), starting in September, and concluding in December of the following year. Students will complete their practicum during the summer.

Yes, upon entry to the program, each student will be paired with a Harvard-affiliated advisor who will provide academic guidance and assist them with course selection. Students may also be able to work with other faculty based on their interests.

Information on financial aid is available here .

Currently, no. If you are interested in becoming a Registered Dietitian, please refer to this website which lists accredited programs in dietetics.

Yes, students may have the opportunity to take courses offered by select Harvard Schools and other universities in the area.

Have another question not answered here?

• For questions related to the nutrition field of study, please contact [email protected] .
• For general MPH questions, please contact [email protected] or visit the MPH program page .

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Nutrition Education and Health

Connecting health and food access.

Health is important for everyone, no matter their age. When someone doesn’t have enough food or can only afford foods with low nutritional value, it can seriously impact their health. 

Our health and nutrition programs go beyond just providing meals. We focus on how food access can improve overall health and well-being. We work with food banks and partners nationwide to address food insecurity, nutrition, and health. 

Access to Healthy Foods

Promoting nutrition means ensuring people can access foods that fight disease, respect their cultural traditions, and promote wellness.

Nutrition Education

Food banks are crucial in providing education that empowers individuals to make healthier choices. Knowledge is key to making positive changes in our overall health.

Health Partnerships

By forming strong partnerships with health care providers, we can reach more people at risk of  food insecurity , improve nutrition, and achieve health equity.

Why Health and Nutrition Matter

Food insecurity, nutrition, and health are closely connected. People facing food insecurity have few options for nutritious foods and healthy eating. Poor nutrition increases the risk of health issues like  diabetes and hypertension . Food insecurity makes managing a chronic disease even harder.

At Feeding America, we actively address these challenges.

Food As Medicine

Food banks work with health care partners to identify patients facing food insecurity during their visits. They then provide food assistance at health care facilities, food pantries, or meal programs.

Health Equity

Food insecurity is connected to poverty, poor diet quality, and chronic disease – the social determinants of health. Feeding America supports food banks with educational programs and grants to reduce disparities in their communities.

Creating healthy communities requires access to culturally diverse, nutritious food. Food banks empower our neighbors by sourcing foods that reflect their food traditions and lifestyles and positively impact health and nutrition.

Feeding America helps local food banks with food, funds, and capacity building so that together we can serve more of our neighbors facing hunger across the United States.

We advocate for strong federal food and nutrition programs for children, seniors, and families.

Explore our original research on how food insecurity impacts physical and mental health.

Farm Partnerships

Discover how Feeding America works with farms to provide access to nutritious foods.

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Advancing nutrition knowledge, skills, and attitudes in medical education and training: key themes and recommendations from the 2023 Summit

Affiliations.

• 1 Accreditation Council for Graduate Medical Education, 401 North Michigan Ave, Suite 2000, Chicago IL 60611, USA. Electronic address: [email protected].
• 2 Accreditation Council for Graduate Medical Education, 401 North Michigan Ave, Suite 2000, Chicago IL 60611, USA.
• PMID: 39232604
• DOI: 10.1016/j.ajcnut.2024.05.028

The incorporation of comprehensive nutrition education into medical education and training is essential for equipping physicians with the knowledge and skills necessary to enhance patient health and outcomes. However, a deficiency in nutrition education persists in medical education, rendering physicians ill-prepared to address the vital role of nutrition in health and disease. This article summarizes the key themes and recommendations generated during the Summit on Medical Education in Nutrition, hosted in March 2023 by the Accreditation Council for Graduate Medical Education in collaboration with American Association of Colleges of Osteopathic Medicine and Association of American Medical Colleges.

Keywords: GME; UME; food is medicine; medical education; nutrition; residency; training.

Copyright © 2024 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.

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Health, well-being and education: Building a sustainable future. The Moscow statement on Health Promoting Schools

Health Education

ISSN : 0965-4283

Article publication date: 18 March 2020

Issue publication date: 4 June 2020

The purpose of this paper is to introduce the official statement of the Fifth European Conference on Health-Promoting Schools.

Design/methodology/approach

The Fifth European Conference on Health-Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries. A writing group was established to prepare a draft version of the statement before the conference. On the basis of an online and offline feedback process, the opinions of the participants were collected during the conference and included in the finalisation of the statement.

The final conference statement comprises six thematic categories (values and principles; environment, climate and health; schools as part of the wider community; non-communicable diseases (NCDs); evidence base; and digital media), with a total of 23 recommendations and calls for action.

Originality/value

The recommendations and calls for action reflect current challenges for Health Promoting Schools in Europe. They are addressed to all actors in governmental, non-governmental and other organisations at international, national and regional levels involved in health promotion in schools and are to be applied for the further development of the concept.

• Health Promoting Schools
• Social change
• Child and adolescent health
• School health promotion

Dadaczynski, K. , Jensen, B.B. , Viig, N.G. , Sormunen, M. , von Seelen, J. , Kuchma, V. and Vilaça, T. (2020), "Health, well-being and education: Building a sustainable future. The Moscow statement on Health Promoting Schools", Health Education , Vol. 120 No. 1, pp. 11-19. https://doi.org/10.1108/HE-12-2019-0058

Emerald Publishing Limited

Copyright © Kevin Dadaczynski, Bjarne Bruun Jensen, Nina Grieg Viig, Marjorita Sormunen, Jesper von Seelen, Vladislav Kuchma and Teresa Vilaça

Published in Health Education . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at: http://creativecommons.org/licences/by/4.0/legalcode

1. The Health Promoting Schools approach and its development

The Ottawa Charter, adopted in 1986, was a milestone in the development of a holistic and positive understanding of health that requires actions at different levels, from healthy public policy to the development of personal skills, using different strategies, such as enabling and advocacy approaches ( WHO, 1986 ). The charter can also be regarded as marking the birth of whole-school approaches to health that have been established in Europe and internationally under the term Health Promoting Schools ( Stewart Burgher et al. , 1999 ).

A Health Promoting Schools reflects a holistic approach that moves beyond individual behaviour change by also aiming at organisational change through strengthening the physical and social environment, including interpersonal relationships, school management, policy structures and teaching and learning conditions. This approach can be seen as the result of overcoming traditional health education at school, which aimed to influence students' knowledge, attitudes and behaviour ( Clift and Jensen, 2005 ). In accordance with a social-ecological perspective, health is considered to be the result of a complex interplay of individual, social, socio-economic and cultural factors ( Dahlgreen and Whitehead, 1991 ). Since the early 1990, actions on school health promotion have been coordinated in national networks and the European network on Health Promoting Schools as a WHO supported network. The current work on school health promotion on a European level is organised through the Schools for Health in Europe Network Foundation (SHE), with national representatives from 36 countries.

Values of the Health Promoting Schools approach

Health Promoting Schools ensure equal access for all to the full range of educational and health opportunities. This in the long term makes a significant impact in reducing inequalities in health and in improving the quality and availability of lifelong learning.

Sustainability

Health Promoting Schools acknowledge that health, education and development are closely linked. Schools act as places of academic learning. They support and develop a positive view of pupils' future role in society. Health Promoting Schools develop best when efforts and achievements are implemented in a systematic and continuous way. Desirable and sustainable health and educational outcomes occur mostly in the medium or long term.

Health Promoting Schools celebrate diversity and ensure that schools are communities of learning, where all feel trusted and respected. Good relationships among pupils, between pupils and school staff and between school, parents and the school community are important.

Empowerment

Health Promoting Schools enable children and young people, school staff and all members of the school community to be actively involved in setting health-related goals and in taking actions at school and community level to reach the goals.

Health Promoting Schools are based on democratic values and practise the exercising of rights and taking responsibility.

Pillars of the Health Promoting Schools approach

Whole-school approach to health

Taking a participatory and action-oriented approach to health education in the curriculum;

Taking into account the pupil's own concept of health and well-being;

Developing healthy school policies;

Developing the physical and social environment of the school;

Developing life competencies and health literacy;

Making effective links with home and the community; and

Making efficient use of health services.

Participation

A sense of ownership is fostered by pupils, staff and parents through participation and meaningful engagement, which is a prerequisite for the effectiveness of health-promoting activities in schools.

School quality

Health Promoting Schools support better teaching and learning processes. Healthy pupils learn better, and healthy staff work better and have greater job satisfaction. The school's main task is to maximise educational outcomes. Health Promoting Schools support schools in achieving their educational and social goals.

School health promotion in Europe is informed by existing and emerging research and evidence focused on effective approaches and practice in school health promotion, both on health topics (such as mental health, eating and substance use) and on the whole-school approach.

Schools and communities

Health Promoting Schools engage with the wider community. They endorse collaboration between the school and the community and are active agents in strengthening social capital and health literacy.

Since the establishment of the European network of Health Promoting Schools, four European conferences on Health Promoting Schools have been organised. The resolution of the first conference, held in Thessaloniki, Greece, in 1997, stated that every child and young person in Europe had the right to be educated in a Health Promoting Schools and urged governments in all European countries to adopt the Health Promoting Schools approach ( ENHPS, 1997 ). The Egmont Agenda was published in 2002 as a result of the Second European Conference on Health Promoting Schools in The Netherlands and emphasised conditions, programming and evaluation as being essential to developing and sustaining Health Promoting Schools ( ENHPS, 2002 ).

Seven years later, the Third European Conference on Health Promoting Schools was held in Vilnius, Lithuania ( SHE Network, 2009 ). The conference and its resolution marked an important milestone in the development of the Health Promoting Schools approach by highlighting that education and health have shared interests and complement each other. Based on this, joint actions beyond sectoral responsibilities were urged.

The Fourth European Conference was held in Odense, Denmark, in 2013 and resulted in The Odense Statement, which recognised the core values and pillars of school health promotion as a strong contributor to the aims and objectives of the WHO policy framework for health and well-being in Europe, Health 2020 and the EU2020 strategy for inclusive and sustainable growth ( SHE Network, 2013 ).

2. Recent societal challenges

Since the establishment of the Health Promoting School approach in the late 1980s, the world has seen constant societal change, with progressively faster dynamics during recent years. The changes have not only altered substantially the conditions in which people grow up and live, but have also affected behaviours in relation to health, social cohabitation, learning and working. Wars and violence, often rooted in cultural and religious differences or political and economic crisis, and climate change alter significantly the environmental and societal determinants of health ( Mucci et al. , 2016 ; Watts et al. , 2019 ).

Often, it is countries that already are experiencing political and socio-economic instability that feel the effects most ( Reibling et al. , 2017 ). An increase in international migration, commonly in perilous circumstances for migrants and refugees ( Silove et al. , 2017 ), is the consequence, raising social tensions and challenges in many countries, some of which are undergoing political developments characterised by protectionism and isolationism that can partly be seen as a countermovement to the idea, values and principles of Europe ( Harteveld et al. , 2018 ).

In many cases, uncertainty has replaced political, economic, social and individual stability, raising concern and anxiety about the future in young people and adults. This has led to an unprecedented social (grassroots) movement of participation, primarily driven by young people who are demanding social, political, ecological and economic change ( O'Brien, Selboe and Hayward, 2018 ).

These developments should not be seen as being separate from school health promotion, the aim of which is to support young people to develop healthy and self-determined lifestyles and enable them to co-create their social, physical and ecological environments and the determinants of health positively and sustainably ( Clift and Jensen, 2005 ; Simovska and McNamara, 2015 ). As the conditions for growing up and living together change, the question arises of how schools, as places for health-related teaching, learning and development, need to adapt.

Where does the Health Promoting School approach stand today, more than 30 years after the Ottawa Charter on health promotion? Can the Health Promoting School, with its holistic orientation, deliver on its promise of addressing health inequalities and improving children's and young people's health, well-being and academic achievement? To what extent can school health promotion be implemented systematically in schools and be linked to local communities?

These and more questions were raised and discussed during the Fifth European Conference on Health Promoting School, culminating in recommendations for the future development of the Health Promoting School approach.

3. The Fifth European Conference on Health Promoting Schools

The Fifth European Conference on Health Promoting Schools was held on 20–22 November 2019 in Moscow, Russian Federation, with over 450 participants from 40 countries.

A range of topics was addressed through more than 160 contributions and nine keynote presentations focusing on conceptual aspects of the Health Promoting School approach, implementation and dissemination and current social change processes, such as digitisation and heterogeneity.

Holistic approaches to school-based health promotion and health education (such as organizational change and environmental approaches to school health promotion and strategies to promote individual and organizational health literacy in schools);

Implementation and dissemination of school-based health promotion and health education (facilitators and barriers to implementing interventions in school-based health promotion and professional development and capacity-building of, for example, teachers, non-teaching school staff, school health services, parents and external professionals);

Networking and intersectoral collaboration in school-based health promotion and health education (schools as part of the wider community, and multisectoral partnerships at local, national and international levels);

Innovative approaches to dealing with heterogeneity, inclusion and special needs (pupils' and teachers' health in inclusive schooling, school-based health promotion and education for refugees, students with special needs and innovative approaches to school-based health services); and

Digital media and information and communications technology (ICT) in school health promotion and health education (practical approaches to ICT use in school-based health promotion and digital devices and media as a target for interventions and a means to promote health and well-being).

4. Recommendations for action

Be based on democratic processes and foster equal access, active involvement and participation;

Take into account the needs and background of all young people regardless of their gender, geographical, cultural and social background or religious beliefs: in that sense, a Health Promoting School can be seen as an inclusive school that celebrates heterogeneity and diversity as an enriching dimension for mutual learning, respect and acceptance;

Reflect a whole-school approach addressing different target groups and combining classroom activities with development of school policies, the physical, social and cultural environment of the school and the necessary capacities needed: we welcome new and established concepts and approaches within school-based health promotion, such as health literacy, salutogenesis, action competence and life skills, which should complement each other and be integrated in the holistic framework of the Health Promoting School approach; and

Be systematically linked with educational goals and school quality as part of a so-called add-in approach: based on rich evidence, a Health Promoting School can be regarded as a school that not only promotes and maintains health, but also strives for successful learning for pupils and working conditions for teaching and non-teaching staff, and involves parents and families in the school's daily life.

Urge all stakeholders in health and climate/sustainability education to work together systematically to support young people to grow up and live healthily and sustainably;

Urge all stakeholders to support and empower young people to raise their voice and make a lasting contribution to shaping a healthy and sustainable future for themselves and their fellow human beings;

Call for actions to link planetary health and the Health Promoting School approach more explicitly by, for instance, integrating the impact of human action on the environment and its health consequences into school curricula and everyday life; and

Call for realignment of health-promotion research agendas to address environmental challenges in, with and through schools.

All actors to move from a single-setting approach to an integrated multi-setting approach that systematically links actions at school level with actions in the local community: these actions should not be implemented in isolation, but in a coordinated fashion to create synergies and avoid discontinuities;

Intersectoral collaboration among different actors and professions, such as teachers, school health services and social and youth-care services: this requires professional development, and that existing local networks and their leadership capacities be strengthened to align sectoral policies and enable the development of a common vision and language; and

All actors to strengthen links with existing national and regional cooperation mechanisms, such as Health Promoting School networks and healthy city or healthy region networks, by pursuing joint objectives and actions.

A resource-oriented intervention approach (as described in the SHE values and pillars) be taken to tackle NCDs rather than a traditional top-down and disease-oriented approach, which normally dominates interventions related to risk factors;

Young people be viewed as part of the solution and not only as part of the problem of NCDs – we need to work with young people as powerful agents of healthy change and not as victims and recipients of risk factors;

A school environment that promotes healthy practices in areas like healthy eating, physical activity, social and emotional well-being and good hygiene be created; and

Commercial determinants are addressed by empowering young people to become critical and responsible citizens who are able to understand and critically reflect on media advertising and market mechanisms through, for instance, consumer education.

Call for evaluation approaches that reflect the complexity of the Health Promoting School by, for example, applying mixed-methods designs and considering graded health and educational outcomes;

Demand that the available scientific evidence be reviewed and evaluated using existing tools and be translated into recommendations for practical action;

Urge that a one-sided focus on outcomes research be augmented by focusing also on implementation to identify the conditions under which interventions can be effective, systematically linking both research perspectives; and

Call for systematic and strong partnerships between researchers and practitioners who develop and implement innovative interventions in school health promotion and those who conduct empirical surveys on child and adolescent health (such as the Health Behaviour in School-aged Children (HBSC) study) and the health of teaching and non-teaching staff. By sharing available social-epidemiological data, previously untried evaluation potential can be exploited.

Call on all actors in school health promotion to use the possibilities of digital media in the context of research, development, implementation and exchange of innovative interventions and good practice;

Urge all actors to use digital media as a supplement to, and not as a substitute for, non-digital (face-to-face) school health-promotion actions;

Call on all actors to ensure that the use of digital media does not lead to a step back to individual and behavioural prevention, but rather is used at organisational level to, for instance, build capacity, communicate with partners outside the school and promote low-threshold participation in change processes within the school; and

Call for actions to empower individuals and whole-school systems to deal effectively with health information complexity, including its critical assessment, selection and use and to take responsibility for providing suitable and reliable health information.

The Health Promoting School approach

Buijs , G.J. ( 2009 ), “ Better schools through health: networking for health promoting schools in Europe ”, European Journal of Education , Vol. 44 No. 4 , pp. 507 - 520 .

Clift , S. and Jensen , B.B. ( 2005 ), The Health Promoting School: International Advances in Theory, Evaluation and Practice , Danish University of Education Press , Copenhagen .

Dahlgren , G. and Whitehead , M. ( 1981 ), Policies and Strategies to Promote Social Equality in Health , Institute of Future Studies , Stockholm .

European Network of Health Promoting Schools (ENHPS) ( 2002 ), The Egmond Agenda. A New Tool to Help Establish and Develop Health Promotion in Schools and Related Sectors across Europe , available at: https://tinyurl.com/y2py8wzr ( accessed 19 November 2019 ).

European Network of Health Promoting Schools (ENHPS) ( 1997 ), “ Conference resolution ”, available at: https://tinyurl.com/wcunrec ( accessed 19 November 2019 ).

Harteveld , E. , Schaper , J. , De Lange , S.L. and Van Der Brug , W. ( 2018 ), “ Blaming Brussels? the impact of (news about) the refugee crisis on attitudes towards the EU and national politics ”, JCMS: Journal of Common Market Studies , Vol. 56 No. 1 , pp. 157 - 177 .

Mucci , N. , Giorgi , G. , Roncaioli , M. , Perez , J.F. and Arcangeli , G. ( 2016 ), “ The correlation between stress and economic crisis: a systematic review ”, Neuropsychiatric Disease and Treatment , Vol. 12 , pp. 983 - 993 .

O'Brien , K. , Selboe , E. and Hayward , B. ( 2018 ), “ Exploring youth activism on climate change: dutiful, disruptive, and dangerous dissent ”, Ecology and Society , Vol. 23 No. 3 , p. 42 .

Reibling , N. , Beckfield , J. , Huijts , T. , Schmidt-Catran , A. , Thomson , K.H. and Wendt , C. ( 2017 ), “ Depressed during the depression: has the economic crisis affected mental health inequalities in Europe? findings from the European social survey (2014) special module on the determinants of health ”, The European Journal of Public Health , Vol. 27 Suppl 1 , pp. 47 - 54 .

Schools for Health in Europe (SHE) Network ( 2013 ), “ The Odense Statement. Our ABC for equity, education and health ”, available at: https://tinyurl.com/rk8rh5e ( accessed 19 November 2019 ).

Schools for Health in Europe (SHE) Network ( 2009 ), “ Better schools through health: the Third European Conference on Health Promoting Schools. Vilnius resolution ”, available at: https://tinyurl.com/qskr692 ( accessed 19 November 2019 ).

Silove , D. , Ventevogel , P. and Rees , S. ( 2017 ), “ The contemporary refugee crisis: an overview of mental health challenges ”, World Psychiatry , Vol. 16 No. 2 , pp. 130 - 139 .

Simovska , V. and McNamara , P. (Eds) ( 2015 ), Schools for Health and Sustainability , Springer , Dordrecht .

Stewart Burgher , M. , Barnekow , V. and Rivett , D. ( 1999 ), The European Network of Health Promoting Schools. The Alliance of Education and Health , WHO Regional Office for Europe , Copenhagen .

Watts , N. , Amann , M. , Arnell , N. , Ayeb-Karlsson , S. , Belesova , K. , Boykoff , M. , … and Chambers , J. ( 2019 ), “ The 2019 report of the Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate ”, The Lancet , Vol. 394 No. 10211 , pp. 1836 - 1878 .

WHO ( 2016 ), Declaration: Partnerships for the Health and Well-Being of Our Young and Future Generations. Working Together for Better Health and Well-Being: Promoting Intersectoral and Interagency Action for Health and Well-Being in the WHO European Region , WHO Regional Office for Europe , Copenhagen .

WHO ( 1986 ), “ Ottawa Charter for Health Promotion ”, available at: https://tinyurl.com/mohfbn6 ( accessed 19 November 2019 ).

Acknowledgements

This publication has received funding under an operating grant from the European Union's Health Programme.

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Human Nutrition Research Center hopes to uncover effects of ‘Traditional Indigenous Foods diet’ on health, well-being

Editor’s note: The announcement below is from the Grand Forks Human Nutrition Research Center, a part of the U.S. Department of Agriculture’s Agricultural Research Service. Researchers there wish to study whether a shift away from a traditional Indigenous diet may be impairing the health of Indigenous people.

UND historians and the United Tribes Technical College in Bismarck collaborated with researchers at the center to develop a traditional Indigenous diet for the study. UND Today is happy to publish this announcement to make Indigenous students, faculty and staff members aware of this interesting opportunity.

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USDA Nutrition Center Seeking American Indian Study Participants

The United States Department of Agriculture (USDA) Agricultural Research Service (ARS) Grand Forks Human Nutrition Research Center (GFHNRC) has opened enrollment for American Indians in the Traditional Indigenous Foods Diet and Health Study, led by a team of human health researchers from the GFHNRC.

By enrolling participants, the study team hopes to uncover the effects that a Traditional Indigenous Foods diet has on the health and well-being of American Indians. American Indians ages 18 to 55, who are healthy and not on a regulated diet or exercise regimen, are eligible to participate.

Some exclusions apply; for example, participants who are pregnant, breastfeeding or lactating; are allergic or averse to any foods in a Traditional Indigenous Foods diet; or are unable to be safely physically active. In addition, participants must be willing to visit the center, consume study foods, wear an activity monitor and have their blood drawn.

Participants are essential partners to our research and are paid honoraria for their participation. Participants who complete the study will receive a free 38-month (individual) or 27-month (family) membership to Choice Health & Fitness or up to $1,610 for participating.

To learn more about this study, call 701.795.8396. To apply online, visit https://www.ars.usda.gov/plains-area/gfnd/gfhnrc/docs/nutrition-studies/traditional-indigenous-foods-diet-and-health-study/ .

About the GFHNRC: Located next to the University of North Dakota campus in Grand Forks, the GFHNRC’s 92,000-square-foot building contains state-of-the-art facilities for nutrition and exercise research. GFHNRC’s research mission primarily is to identify foods and diets, coupled with genetics and physical activity, that sustain and promote health throughout the life cycle.

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Association between the composite dietary antioxidant index and infertility: the national health and nutrition examination survey 2013–2020

• Yang Shen 1 , 2   na1 ,
• Zhanwang Tan 3   na1 ,
• Zibo Duan 1 ,
• Jingxiao Chen 1 ,
• Zijiao Yang 1 &
• Xiaohua Lin   ORCID: orcid.org/0000-0002-7879-6112 1 , 4  

BMC Public Health volume  24 , Article number:  2376 ( 2024 ) Cite this article

Metrics details

The use of antioxidant-rich foods to treat female infertility has received significant attention in recent years. The aim of this study was to investigate the potential correlation between the composite dietary antioxidant index (CDAI) and female infertility.

The participants in the cross-sectional data were women between the ages of 20 and 45 who had complete CDAI-related data and infertility information, which were taken from the National Health and Nutrition Examination Survey (NHANES) conducted between 2013 and 2020. The independent association between CDAI and infertility was investigated using multivariate logistic regression analysis. Trends between the two variables were examined using smoothed curve fitting, and subgroup analysis and interaction tests were conducted.

The prevalence of infertility was 12.57% of the 3,259 participants included in the study; individuals in higher CDAI quartiles tended to have a lower percentage of infertility. The risk of infertility was 44% lower among individuals in the highest quartile of the CDAI compared to those in the lowest quartile (OR = 0.56, 95%CI: 0.36–0.85, P  = 0.0072), and the test for trend was also significant ( P  for trend = 0.0235). Smoothed curve fitting showed a negative non-linear relationship between CDAI and infertility. Subgroup analysis and interaction tests showed that there was an interaction of BMI in the relationship between CDAI and infertility risk ( P  for interaction = 0.0497) and that education, PIR, marital status, smoking status, hypertension, diabetes, age at menarche, ever having been treated for pelvic infection, ever having used female hormones, and ever been pregnant had no significant dependence on this negative association (all P  for interaction > 0.05).

There was a negative non-linear correlation between CDAI and infertility among reproductive-aged women in the US. The risk of infertility may be reduced by increasing the intake of antioxidant-rich foods.

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Introduction

Infertility is defined as the inability to conceive after 12 months or more of regular, unprotected sexual behavior or due to reduced fertility, either alone or with a partner [ 1 ]. The prevalence of infertility has been increasing annually in recent years, affecting 15% of couples of reproductive age globally [ 2 , 3 ]. In addition to its definition as the inability to conceive, infertility has been demonstrated to have a significant impact on women’s psychological well-being, quality of life, and long-term health [ 4 , 5 ]. Consequently, it has become a significant public health issue.

An individual’s dietary antioxidant capacity is measured by the composite dietary antioxidant index (CDAI), which is calculated based on the dietary intake of minerals and vitamins that possess antioxidant qualities, such as zinc, magnesium, selenium, and vitamins A, C, and E [ 6 ]. The current literature indicates that diseases related to oxidative stress (OS), such as heart failure, hyperlipidemia, and chronic obstructive pulmonary disease, are all associated with CDAI [ 7 , 8 , 9 ].

OS is characterized by an imbalance between the body’s reactive oxygen species (ROS) and antioxidants. This imbalance represents a significant contributing factor to the pathogenesis of reproductive disorders, including endometriosis, premature ovarian failure, and infertility [ 10 , 11 ]. Research has been shown that excessive ROS production can lead to damage and senescence of oocyte, failure of implantation, and placental damage, ultimately leading to infertility [ 12 , 13 ]. Therefore, antioxidants are now commonly included in infertility treatment to mitigate the damage of OS and enhance blood circulation of endometrium [ 14 ]. In recent years, there has been growing interest in the relationship between dietary intake of antioxidants and female fertility. Studies have reported that naturally occurring antioxidant compounds found in dietary sources may be useful in treating OS-mediated infertility across both natural and assisted reproductive settings [ 15 ]. It has also been observed that supplementing selenium and vitamin E helps improve OS status in women with ovulatory disorders [ 16 , 17 ]. A greater intake of vitamin C and vitamin E has been shown to reduce the time taken for infertile couples to conceive, according to a study examining the relationship between women’s dietary antioxidant consumption and the time to pregnancy in couples undergoing treatment for infertility-related diseases [ 18 ]. Previous research has also indicated a link between a decreased rate of infertility and consumption of various antioxidant substances [ 19 ]. However, less attention has been given to evaluating the effect of CDAI, an indicator of dietary antioxidant capacity, on infertility risk.

Therefore, the purpose of this study is to investigate the association between CDAI and infertility using information from the National Health and Nutrition Examination Survey (NHANES), which may provide new approaches to infertility treatments and dietary recommendations.

Materials and methods

Data sources.

The NHANES database ( www.cdc.gov/nchs/nhanes.com ) provided the data for this study. It is designed to assess the general health and nutritional status of the US population by collecting data on demographics, socioeconomic status, dietary habits, and health-related data. NHANES was approved by the Ethics Review Board of the National Center for Health Statistics, and informed permission was obtained from each survey respondent before their participation in the study.

Study population

This cross-sectional analysis used data from 2013 to 2020 for a total of 35,706 study participants, excluding 17,616 males, 13,430 females younger than 20 or older than 45 years of age, and 1,401 who did not respond to the “history of infertility” question or had missing data related to the CDAI, and finally. The final analysis sample consisted 3,259 participants. Details of the screening process and the size of the participants are shown in Fig.  1 .

Flowchart of the sample selection from NHANES 2013–2020

Assessment of CDAI

The food and nutrient intake of each participant was collected during the dietary interview section of the NHANES database. Each participant was required to complete a non-continuous 24-hour dietary recall interview for two days. The first dietary interview was conducted in person at the Mobile Examination Center, and the second was conducted by telephone 3 to 10 days later, with the amounts per-intake calculated from dietary recall data on both days. We determined the CDAI using the Wright et al. suggested measure, which is consists of six dietary antioxidants, including magnesium, selenium, zinc, and vitamins A, C, and E [ 6 ].

The following formula was calculated by subtracting the global mean from the average daily intake of the six antioxidants and dividing the result by the global standard deviation:

Assessment of infertility

Infertility is measured by self-reported Reproductive Health Questionnaires for each woman: “Have you ever tried to conceive a child for at least one year without getting pregnant?” Women who answered “yes” were considered infertile.

Covariates in this study included age, race (Mexican American/other Hispanic/non-Hispanic white/non-Hispanic black/other races), education level (Less than 9th grade/9th–11th grade/High school or GED/Some college or AA degree/College graduate or above), ratio of family income to poverty(PIR) (< 1.3/1.3–3.49/≥3.5), energy(kcal), body mass index (BMI) (< 25/25–29.9/≥30), marital status (married or living with a partner/widowed or divorced or separated/never married), smoking status (according to the standard of at least 100 cigarettes per year, it is divided into current > 100 cigarettes, former > 100 cigarettes and have quit smoking, and never < 100 cigarettes), hypertension (yes/no), Diabetes (yes/no), age when first menstrual period occurred (Age ≤ 10/10 < Age ≤ 15/Age > 15), ever treated for a pelvic infection/pelvic inflammatory disease(PID) (yes/no), ever use female hormones (yes/no), ever been pregnant (yes/no).

Statistical analysis

Infertility was categorized as a dichotomous variable with or without infertility. CDAI as a continuous variable is presented as quartiles. Continuous covariates are expressed as mean ± standard deviation, and categorical variables are expressed as percentages. We used weighted chi-squared tests for categorical variables and weighted linear regression models for continuous variables to assess differences between individuals categorized by CDAI quartiles. The independent association between CDAI and infertility was examined in three separate models using multivariate logistic regression models. Model 1 did not adjust for covariates. Model 2 was adjusted for age and race. Model 3 was adjusted for age, race, education level, PIR, energy, BMI, marital status, smoking status, hypertension, diabetes, age when first menstrual period occurred, ever treated for a pelvic infection/PID, ever use female hormones, and ever been pregnant. Subgroup analyses were performed to assess the stability of the association between CDAI and infertility, with stratification factors including education level, PIR, BMI, marital status, smoking status, hypertension, diabetes, age when first menstrual period occurred, ever treated for a pelvic infection/PID, ever use female hormones, and ever been pregnant. An interaction term was included to test for heterogeneity of associations between subgroups. Missing values were input by median for continuous variables or mode for categorical variables of existing cases of those variables. All statistical analyses were performed using EmpowerStats ( http://www.empowerstats.com , X&Y Solutions, Inc., Boston, MA) and R software, and P  < 0.05 was considered statistically significant.

Baseline characteristics of study participants

Table  1 shows the baseline characteristics of all participants. A total of 3,259 participants were enrolled in this study, with a mean age of 32.32 ± 7.60 years. The overall prevalence of infertility was 12.57%, and the prevalence of infertility in quartiles 1–4 was 14.52%, 12.57%, 14.00%, and 9.48%respectively. Compared with the lowest quartile of the CDAI, participants in the highest quartile of the CDAI had lower BMI, smoking rates, age of menarche, PID prevalence, and ever been pregnant, and higher levels of education, family income, calorie intake, and marriage rate when compared to those in the lowest quartile. (all P  < 0.05). There was no statistically significant difference in age, hypertension and diabetes between the different quartiles ( P  > 0.05).

Association of CDAI with infertility

Table  2 shows the association between CDAI and infertility. In comparison to the lowest quartile of CDAI, participants with the highest quartile of CDAI exhibited a 44% reduction in the likelihood of developing infertility, which was statistically significant (OR = 0.56, 95% CI: 0.36–0.85; P  = 0.0072), and the test for trend was also statistically significant ( P  for trend = 0.0235). The relationship between CDAI and infertility was further investigated with smoothed curve fitting, which showed negative nonlinear associations (Fig.  2 ).

Smooth curve fitting for CDAI and infertility

Subgroup analysis

To further explore the factors associated with the association between CDAI and infertility risk, we performed subgroup analysis. All covariables in each subgroup analysis model were adjusted, with the exception of the stratified variables themselves. The results indicated a substantial inverse relationship between CDAI and infertility among individuals with grades 9–11 in education (OR = 0.91, 95% CI: 0.83–1.00), BMI < 25 kg/m 2 (OR = 0.94, 95% CI: 0.90–0.99), who were married or living with a partner (OR = 0.97, 95% CI: 0.94–0.99), had no history of hypertension (OR = 0.97, 95% CI: 0.95–1.00) and had not been infected with pelvic inflammatory disease (OR = 0.98, 95% CI: 0.95–1.00) (all P  < 0.05). The interaction test demonstrated that there was an interaction between BMI in the relationship between CDAI and infertility risk ( P  for interaction = 0.0497). The negative association between CDAI and infertility risk was more pronounced in those with a BMI < 25 kg/m 2 . Furthermore, no significant association was observed between the negative association and other factors, including education level, PIR, marital status, smoking status, hypertension, diabetes, age of menarche, previous treatment for pelvic infection, previous use of female hormones, and previous pregnancy (all P  for interaction > 0.05) (Fig.  3 ).

Subgroup analysis of the association between CDAI and infertility

In the cross-sectional study of 3,259 participants, we observed an inverse association between CDAI and infertility. Subgroup analyses showed that the association between CDAI and infertility risk was influenced by BMI. Our study suggest that increased intake of antioxidant-rich foods may help reduce the risk of infertility.

Effects of antioxidants on infertility

Research on the connection between diet and male fertility have been extensively studied in the past, while there have been few studies on the relationship between CDAI and female infertility. Nowadays, using dietary antioxidants to intervene female infertility has gradually gained attention. Previous research has indicated that antioxidants may be beneficial for women experiencing infertility. In a randomized controlled clinical experiment conducted by Safiyeh et al. on 70 infertility individuals with occult ovarian dysfunction, it was found that supplementation of selenium and vitamin E may decrease ROS overexpression and boost ovarian reserve [ 20 ]. In their study, Jurczewska et al. concluded that antioxidant vitamins (A, C, and E) and minerals have a positive effect on ovulation and fertility in women [ 21 ]. In a cross-sectional study involving 1,713 women, Ji et al. found that a high intake of vitamins A, C, magnesium, and other nutrients was associated with a lower incidence of female infertility [ 19 ]. In cross-sectional research, Adeniyi et al. observed serum zinc and selenium concentrations in Nigerian women with unexplained infertility were significantly lower than in fertile women [ 22 ]. In a case-control study, Kabodmehri et al. identified that the dietary antioxidant index was inversely related to the risk of infertility among Iranian women [ 23 ]. Consistent with previous research reports, this study shows that CDAI is inversely associated with the risk of infertility, suggesting that increased dietary antioxidant intake has a positive effect on infertility.

Effect of OS on infertility

OS is an important pathological process that leads to infertility. It has been demonstrated that OS can accelerate oocyte senescence by increasing the level of inflammatory factors, proteins, and lipid peroxidation, and disrupting vascular homeostasis, thereby reducing ovarian reserve function, potentially leading to infertility and other serious consequences [ 24 ]. Furthermore, excessive ROS may also exert an influence on the normal separation of chromosomes during oocyte meiosis, impair oocyte viability, and reduce the possibility of fertilization [ 12 ]. In addition, OS can also induce endometrial inflammation to make embryo implantation fail and hinder embryo development by altering gene expression [ 25 ]. OS is associated with various reproductive diseases, and excessive ROS in endometriosis may cause adhesions, impair uterine peristalsis, cause developmental inconsistencies between the endometrium and the embryo, and ultimately lead to infertility [ 26 ]. In patients with polycystic ovary syndrome, increased OS markers in oocyte follicular fluid lead to abnormal follicular growth and maturation, poor oocyte or embryo quality, and thus infertility [ 27 ]. Therefore, reducing the detrimental effects of OS on the female reproductive system is of great significance to prevent and improve the reduction of female fertility.

Dietary antioxidants can improve OS to increase pregnancy rates

Antioxidant vitamins and minerals can restore or maintain the oxidation-antioxidant balance in the blood and tissues and are essential for normal ovulation, maintaining pregnancy and reducing adverse pregnancy outcomes [ 21 , 28 ]. According to research by Amini et al., vitamin C and E supplements can effectively reduce the expression level of OS markers in women with endometriosis [ 29 ]. Shi YQ et al. found that natural antioxidants such as vitamins C and E could delay the disease process of premature ovarian aging by reducing ROS levels in the body [ 24 ]. Ozkaya et al. observed that multivitamin and mineral supplementation can reduce OS levels in the serum and follicular fluid of women undergoing in vitro fertilization [ 30 ]. Numerous studies have confirmed that antioxidant supplementation can effectively prevent or assist in the treatment of infertility-related diseases and improve the pregnancy rate [ 31 , 32 ]. The benefits of consuming natural antioxidants from food include their high safety and minimal side effects, garnering increasing interest in its application for treating infertility [ 33 ]. The CDAI is a well-established marker for evaluating the intake of dietary antioxidants, which mirrors an individual’s antioxidant status. Therefore, using the CDAI to assess a patient’s antioxidant capacity might be a more effective approach to assess the relationship between intake of antioxidant-rich food intake and infertility. In Model 3, the risk of infertility in the Q4 group was lower than that in the Q1 group, suggesting that higher CDAI had a positive effect on infertility. Subgroup analysis showed that this negative association was significant in people with grades 9–11, a BMI < 25 kg/m 2 , who were married or living with a partner, had no history of hypertension, and had not been infected with pelvic inflammatory disease. The results showed that for these participants, higher CDAI was associated with a lower risk of infertility. Interaction tests showed that the negative association between CDAI and infertility risk was more significant in those with a BMI < 25 kg/m 2 . However, education, PIR, marital status, smoking status, hypertension, diabetes, age at menarche, previous treatment for pelvic infection, previous use of female hormones, and ever having been pregnant were not dependent on the negative association between CDAI and infertility, suggesting that these negative associations were similar across populations. The results of this study complement and confirm the positive effect of higher CDAI on reducing the risk of infertility in the general population.

This study used NHANES data to make the study more reliable and representative. In addition, based on the information we could find, we included the largest sample size of previous research looking at the relationship between CDAI and the risk of infertility. Furthermore, we adjusted covariates related to exposure and outcome to ensure that our results are applicable to a broad population. However, this study has certain limitations. First, the cross-sectional research design of the NHANES made it impossible for us to establish a causal relationship between CDAI and the risk of infertility. Second, the NHANES database lacks information on the causes of infertility, and some infertile populations may be caused by factors unrelated to dietary intake, such as uterine malformations and tubal obstruction. It was also not possible to explore in depth the relationship between CDAI and infertility-related gynecological disorders, such as polycystic ovary syndrome and endometriosis. Third, the evaluation of an individual’s dietary intake relies on the mean of two 24-hour dietary recall interviews, and it could be subject to bias.

Our study shows that there is a negative non-linear correlation between CDAI and infertility among reproductive-aged women in the US, suggesting that increasing dietary intake of antioxidants may play a key role in reducing the risk of infertility. Further prospective studies are needed to verify our findings.

Data availability

The data used for this study are available at the NHANES online website ( https://www.cdc.gov/nchs/nhanes/index.htm ).

Abbreviations

Body mass index

Composite dietary antioxidant index

National Health and Nutrition Examination Survey

• Oxidative stress

Pelvic inflammatory disease

Ratio of family income to poverty

Reactive oxygen species

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Acknowledgements

Special thanks to NHANES for providing public data. Thanks to all the staff and participants who participated in NHANES 2013-2020.

The study was funded by the Youth Science Foundation of the National Natural Science Foundation of China (81403428), the Scientific Research Project of the Administration of Traditional Chinese Medicine of Hebei Province (2024019), and the Natural Science Foundation of Hebei Province (H2024423019).

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Yang Shen and Zhanwang Tan contributed equally to this work.

Authors and Affiliations

First Affiliated Hospital of Hebei University of Chinese Medicine, Shijiazhuang, Hebei, 050011, People’s Republic of China

Yang Shen, Zibo Duan, Jingxiao Chen, Zijiao Yang & Xiaohua Lin

Hebei Key Laboratory of Integrative Medicine On Liver-Kidney Patterns, Hebei University of Chinese Medicine, Shijiazhuang, Hebei, 050091, People’s Republic of China

College of Integrative Chinese and Western Medicine, Hebei Medical University, Shijiazhuang, 050031, People’s Republic of China

Zhanwang Tan

Hebei Key Laboratory of Turbidity Toxin Syndrome, First Affiliated Hospital of Hebei, University of Chinese Medicine, No.389 Zhongshan East Road, Chang ’an District, Shijiazhuang City, Hebei Province, 050011, People’s Republic of China

Xiaohua Lin

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YS and ZWT designed the study. ZBD and JXC collected the data. ZWT and ZJY analyzed the data. YS edited the original manuscript. XHL reviewed and edited the manuscript. All the authors read and approved the final manuscript.

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Correspondence to Xiaohua Lin .

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The study was conducted in accordance with the guidelines set forth in the Declaration of Helsinki and was approved by the Research Ethics Review Board of the National Center for Health Statistics. All NHANES participants provided written informed consent to participate in this study.

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Shen, Y., Tan, Z., Duan, Z. et al. Association between the composite dietary antioxidant index and infertility: the national health and nutrition examination survey 2013–2020. BMC Public Health 24 , 2376 (2024). https://doi.org/10.1186/s12889-024-19933-5

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Diabetic Attacks and Emergencies

Understanding blood sugar, diabetic ketoacidosis, hypoglycemia, hyperglycemia, increased risk of infections, diabetic coma, preeclampsia, heart attack or stroke.

A diabetic attack occurs when your blood sugar spikes too high or drops too low. This can cause a medical emergency.

A number of different conditions and factors can lead to a diabetic emergency, including ketoacidosis , hyperglycemia , and hypoglycemia . Each of these needs to be handled in a specific way to reduce the risk of long-term consequences.

This article explains types of emergencies that can result from diabetic attacks, their symptoms, and treatment options. It also covers possible complications and how to prevent attacks and problems.

Diabetes is a chronic condition where the blood sugar level is too high. Insulin, a hormone produced by the pancreas , removes sugar from the blood and moves it into cells for the body to use. In people with type 1 diabetes , their pancreas doesn’t make any insulin; in those with type 2 diabetes , it doesn’t make enough.

Having high blood sugar for a long period of time puts people with diabetes at risk for other health problems, such as kidney disease, heart disease , stroke , and nerve damage.

A diabetic emergency happens when blood sugar is too high or too low for too long. This is a life-threatening condition that requires immediate medical treatment. There are a few types of diabetic emergencies, and some conditions may increase the risk of a diabetic emergency.

Diabetic ketoacidosis (DKA) occurs when the body begins burning fat, instead of sugar, for fuel. This happens when there isn’t enough insulin to deliver sugar to cells for energy.

To make up for this, the liver begins breaking down fat too quickly for the body to process. This can lead to a buildup of ketones (a type of acid) in the blood, which can become poisonous.

Symptoms of DKA can include:

• Rapid breathing
• Flushed face
• Nausea, vomiting, or abdominal pain
• Decreased alertness
• Frequent urination or thirst that lasts for a day or more
• Dry skin or mouth
• Muscle stiffness or aches
• Dehydration
• Fruity breath

DKA is most common in individuals with type 1 diabetes. It can sometimes be the first sign of type 1 in those who are not diagnosed. Causes of DKA in type 1 diabetes include infection, injury, serious illness, missed insulin doses, or stress due to surgery.

DKA is less common in people with type 2 diabetes. If it occurs, it is typically less severe. Causes of DKA in type 2 diabetes include uncontrolled high blood sugar for a long period of time, missing medicine doses, or a severe illness or infection. It can also be a side effect of some medications for diabetes, such as sodium-glucose transport protein 2 (SGLT2) inhibitors.

When you eat too much sugar, the excess is stored in the muscles and liver. When blood sugar decreases, the liver releases what it has stored, raising the amount of sugar in the blood. For some, especially those with diabetes, their blood sugar doesn’t go up enough and is below 70 mg/dL, causing hypoglycemia, or low blood sugar.

Possible symptoms of hypoglycemia include:

• Fast breathing
• Sweating or chills
• Fast heartbeat
• Lightheadedness or dizziness
• Irritability
• Color draining from the skin
• Blurred vision
• Tingling or numbness in the lips, tongue, or cheeks
• Coordination problems

Hypoglycemia can happen to anyone, but for people with diabetes, hypoglycemia can occur as a side effect of the medicine they’re taking. Eating foods high in carbohydrates usually helps raise your blood sugar to normal levels.

If hypoglycemia happens too often, they need to consult with their healthcare provider to see if they need to change their treatment plan.

Hyperglycemia is blood glucose greater than 125 mg/dL while fasting, which is defined as not eating for at least eight hours.

It can occur in people with diabetes if they’re eating too many carbohydrates, taking their medicine incorrectly, or if their medication is not as effective as it should be.

Stress and the dawn phenomenon (a surge of hormones that leads to high blood sugar in the morning), could also lead to hyperglycemia.

  Symptoms of hyperglycemia can include:

• Increased urination or thirst
• Slow-healing cuts and sores

Hyperglycemic hyperosmolar syndrome (HHS) can occur if you have a high blood sugar level for a long time. Signs of HHS can include:

• Blood sugar over 600 mg/dL
• Extreme thirst or dry mouth
• Confusion, hallucinations, drowsiness, or passing out
• Fever over 100.4 degrees F
• Weakness or paralysis on one side of the body
• Frequent urination

HHS usually develops in people who do not have their type 2 diabetes under control and who have an infection, stopped taking their medications, have a heart attack or stroke, or take medicine that can cause this condition, such as steroids and diuretics.

High blood sugar can negatively affect the immune system. It can lower the ability of white blood cells to come to the site of an infection and kill what is causing the infection. Nerve damage and difficulty breaking down and storing fats can contribute to an increased risk of infection.

People with type 1 or type 2 diabetes are vulnerable to infections that can become life-threatening, including:

• Fungal infections, such as jock itch, athlete’s foot, ringworm , and vaginitis
• Urinary tract infections
• Bacterial infections of the skin and soft tissue that won’t heal

Signs of infection can include fever, chills, sore throat or mouth sores, redness or swelling, or pain with urination.

A diabetic coma , where a person passes out due to extremely low or high blood sugar, is an emergency that requires immediate medical attention. Extreme hypoglycemia or hyperglycemia can cause a diabetic coma, so symptoms of these two conditions could be warning signs of this diabetic emergency.

Other circumstances can also increase the risk of diabetic coma, such as:

• Surgery or other bodily trauma
• Illness or infection
• Drinking alcohol
• Skipping insulin doses
• Poor diabetes management

Diabetic ketoacidosis and hypoglycemia are more likely to cause a diabetic coma in those with type 1 diabetes, while HHS places people with type 2 diabetes more at risk of this condition.

When to Call Your Healthcare Provider

You should call your healthcare provider or 911 if you have diabetes and the following:

• Your blood sugar is 300 mg/dL or higher two times in a row for an unknown reason.
• You have low blood sugar that has not come up after three treatments.

Preeclampsia is pregnancy-induced high blood pressure ( hypertension ) and liver or kidney damage. It often occurs after the 20 th week of pregnancy. The risk of preeclampsia is two to four times higher among people with type 1 or type 2 diabetes. Gestational diabetes , a type of diabetes that occurs during pregnancy, also increases your risk of developing preeclampsia.

The exact cause of preeclampsia is unknown. It is estimated to occur in about 3% to 7% of all pregnancies.  

Women with preeclampsia often do not feel sick, but symptoms in the early stages could include:

• Swelling of the hands and face or eyes
• Sudden weight gain over one to two days or more than two pounds a week
• Headache that does not go away or becomes worse
• Trouble breathing
• Belly pain on the right side, below the ribs
• Not urinating very often
• Nausea and vomiting
• Vision changes, such as temporary blindness, seeing flashing lights or spots, sensitivity to light, and blurry vision
• Feeling lightheaded or faint

Even when diabetes is controlled, high blood sugar can still damage the blood vessels and nerves of the heart over the years. The longer you have diabetes, the higher the chances that you will develop heart disease . This increases the risk of heart attack or stroke.

Signs of a heart attack can include:

• Pain or pressure in your chest that lasts longer than a few minutes or goes away and returns
• Pain or discomfort in one or both arms, or the shoulders, back, neck, or jaw
• Shortness of breath
• Sweating or lightheadedness
• Feeling extreme fatigue
• Indigestion or nausea

Women are more likely to experience nausea or vomiting, back or jaw pain, and shortness of breath as heart attack symptoms.

Signs of a stroke are:

• Sudden numbness or weakness on one side of the body
• Trouble seeing or walking
• Sudden severe headaches with no known cause
• Confusion, difficulty speaking or understanding speech

If you experience any of these symptoms, call 911 immediately.

To avoid a diabetic emergency, you must manage your diabetes as well as possible. Check your blood sugar often, and get into the habit of recognizing the early signs that levels are rising or dropping toward a dangerous range.

Other tips to prevent a diabetic emergency include:

• Eat regularly and avoid foods that are processed or have added sugar
• Stay active and exercise regularly
• Take medications as prescribed

It’s also a good idea to carry snacks that you can eat to quickly get sugar into your blood to treat hypoglycemia. These might include raisins, candy, or glucose tablets.

For hyperglycemia, exercise will lower your blood sugar, but if your blood sugar is above 240 mg/dL, you need to check your urine for ketones. Exercising with a high ketone level will raise your blood sugar even higher.

If you are pregnant, your healthcare provider may recommend that you take daily low-dose aspirin to help prevent preeclampsia and its related complications. It is started between 12 to 28 weeks of pregnancy, but it is best to start before 16 weeks of pregnancy.

Diabetic attacks can be caused by hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar), which can cause medical emergencies. Too little insulin can also cause an emergency condition known as diabetic ketoacidosis. During pregnancy, high blood pressure can also put you at risk for a diabetic attack.

Uncontrolled diabetes results in more than a diabetic attack, though. It also increases susceptibility to infections and puts you at risk for suffering from a diabetic coma.

There are steps you can take to reduce your risk and maintain a stable sugar level.

A Word From Verywell

Managing diabetes and the possibility of diabetic emergencies can feel overwhelming, but these emergencies are largely preventable by keeping your condition under control.

Eating healthy, taking medicines as prescribed, exercising regularly, and recognizing the early signs of rising or falling blood sugar levels can help you keep these emergencies at bay and become prepared in the event that they do occur.

National Institutes of Health. What is diabetes ?

American Diabetes Association. Hypoglycemia (low blood sugar) .

MedlinePlus. Diabetic ketoacidosis .

National Institute of Diabetes and Digestive and Kidney Diseases. Hypoglycemia .

American Diabetes Association. Hyperglycemia (high blood sugar) .

MedlinePlus. Diabetic hyperglycemic hyperosmolar syndrome .

Stoner GD. Hyperosmolar hyperglycemic state . Am Fam Physician ; 96(11):729-736.

Carey IM, Critchley JA, DeWilde S, Harris T, Hosking FJ, Cook DG. Risk of infection in type 1 and type 2 diabetes compared with the general population: a matched cohort study . Diabetes Care . 2018;41(3):513-521. doi:10.2337/dc17-2131

Centers for Disease Control and Prevention. Know the signs and symptoms of an infection .

Cleveland Clinic. Diabetic coma .

Weissgerber TL, Mudd LM. Preeclampsia and diabetes . Curr Diab Rep . 2015;15(3):9. doi:10.1007/s11892-015-0579-4

MedlinePlus. Preeclampsia .

National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes, heart disease, and stroke .

American Heart Association. Heart attack symptoms in women .

Centers for Disease Control and Prevention. Stroke signs and symptoms .

American Diabetes Association. Eating well .

U.S. Preventive Services Task Force. Aspirin use to prevent preeclampsia and related morbidity and mortality: U.S. Preventive Services Task Force recommendation statement .

By Carisa Brewster Brewster is a freelance journalist with over 20 years of writing experience specializing in science and healthcare content.

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• 2020-2025 Dietary Guidelines for Americans. U.S. Department of Health and Human Services and U.S. Department of Agriculture. https://www.dietaryguidelines.gov. Accessed June 13, 2023.
• Zeratsky KA (expert opinion). Mayo Clinic. June 21, 2023.
• Hensrud DD, ed. Add 5 habits. In: The Mayo Clinic Diet. 3rd ed. Mayo Clinic Press; 2023.
• Dietary supplements: What you need to know. Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/WYNTK-Consumer/ Accessed June 13, 2023.
• Vitamins, minerals and supplements: Do you need to take them? Academy of Nutrition and Dietetics. https://www.eatright.org/health/essential-nutrients/supplements/vitamins-minerals-and-supplements-do-you-need-to-take-them. Accessed June 22, 2023.

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